DOI: 10.1002/smi.3039 - Revised: 13 January 2021 Accepted: 24 February 2021 REVIEW ARTICLE Coping among public safety personnel: A systematic review and meta–analysis Paula M. Di Nota1,2 | Emily Kasurak3 | Anees Bahji4 | Dianne Groll3 | Gregory S. Anderson5 1 Office of Applied Research and Graduate Studies, Justice Institute of British Columbia, New Westminster, BC, Canada Abstract Public safety personnel (PSP) are routinely exposed to potentially psychologically 2 Department of Psychology, University of Toronto, Toronto, Canada 3 Department of Psychiatry, Queen's University, Kingston, Ontario, Canada 4 Department of Psychiatry, University of Calgary, Calgary, Canada 5 Faculty of Science, Thompson Rivers University, Kamloops, Canada traumatic events (PPTEs) that, in turn, can result in posttraumatic stress injuries (PTSI), including burnout and increased symptoms of depression and anxiety. However, the longitudinal impact of PPTEs on PSP coping remains unclear. Coping can be operationalized as various strategies (i.e., behaviours, skills, thought and emotion regulation) for dealing with stressors, which are broadly categorized as either approach (adaptive, positive, social support) or avoidant coping strategies (maladaptive withdrawal, avoidance, substance use). This systematic review and Correspondence Gregory S. Anderson, Faculty of Science, Thompson Rivers University, TRU Way, Kamloops, BC V2C 0C8, Canada. Email: ganderson@tru.ca meta‐analysis aims to evaluate longitudinal coping outcomes among PSP. Thirteen eligible repeated‐measures studies explicitly evaluated coping in 1854 police officers, firefighters, and rescue and recovery workers. Study designs included randomized‐control trials, within‐subject interventions and observational studies. Funding information Institute of Neurosciences, Mental Health and Addiction, Grant/Award Number: 165543 Effect sizes (Cohen's d) at follow‐up were described in 11 studies. Separate meta‐ analyses reveal small (d < 0.2) but non‐significant improvements in approach and avoidant coping. Studies were of moderate quality and low risk of publication bias. [Correction added on March 20, 2021 after first online publication: The first and third affiliations have been updated] Heterogeneity in outcome measures, follow‐up durations, and study types precluded subgroup analyses. The current findings can inform the development and evaluation of organizational training programs that effectively promote sustained adaptive coping for PSP and mitigate PTSIs. KEYWORDS coping, meta‐analysis, occupational health, organizational stress interventions/prevention, posttraumatic stress, public safety personnel, traumatic stress 1 | INTRODUCTION to, police, firefighters, paramedics, border services officers, communications officials (e.g. dispatch or 911 operators), and correctional Public safety personnel (PSP) are at the forefront of keeping com- workers (Canadian Institute for Public Safety Research and Treat- munities safe. The definition of PSP includes, but is not limited ment [CIPSRT], 2020). PSP are more frequently exposed to - This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. © 2021 The Authors. Stress and Health published by John Wiley & Sons Ltd. Stress and Health. 2021;37:613–630. wileyonlinelibrary.com/journal/smi 613 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Received: 15 October 2020 - DI NOTA ET AL. potentially psychologically traumatic events (PPTEs) than the general include seeking social support or adaptive emotion regulation tech- population due to their occupations (Carleton, Afifi, Taillieu, Turner niques such as acceptance and positive reframing (Carver & Connor‐ et al., 2019a, Carleton, Afifi, Turner, Taillieu 2018, 2020). Over time, Smith, 2010). By confronting stressors, approach coping strategies the repeated exposure to PPTEs put PSP at increased risk for enable individuals to (a) minimize the negative psychological impact adverse psychological outcomes, including posttraumatic stress of stressors and (b) promote positive psychological outcomes when injuries Duranceau faced with future stressors. However, avoidant coping refers to any et al., 2018a; Ricciardelli et al., 2020). The term PTSI is a broad strategy that aims to escape or evade a stressor and its related construct that refers to the development of psychopathology emotions (Moos & Schaefer, 1993; Skinner et al., 2003). Examples following exposure to a traumatic event, which may include a include withdrawal or disengagement, denial, wishful thinking, discrete diagnosis of posttraumatic stress disorder (PTSD), although emotion or thought suppression, and substance use (Carver & PTSIs can involve subthreshold symptoms of many mental disorders Connor‐Smith, 2010). Avoidant coping strategies serve to distract (PTSIs) (Carleton, Afifi, Turner, Taillieu, and encompass a range of psychological issues, such as depression, and assuage negative emotions in the immediate or short‐term but anxiety, suicidal ideation, stress, burnout and substance use are often considered ineffective due to their long‐term adverse (Angel, 2016; Carleton et al., 2020; Keynan & Keynan, 2016). There is health implications (Suls & Fletcher, 1985; Wills & Hirky, 1996). mounting evidence that PSP are more likely to experience several Despite the negative connotation of the terms ‘suppressive' or mental disorder sequelae, including increased risk for suicidality (i.e., ‘avoidant', researchers have shown that there are some possible suicidal ideation, planning and attempts) and substance abuse (cf. positive benefits to such an approach (Bonanno et al., 2004). A simple Berger et al., 2012; Carleton, Afifi, Turner, Taillieu, LeBouthillier binary approach to categorizing coping strategies may well over‐ et al., 2018; Di Nota et al., 2020; Stanley et al., 2016). Given the simplify an exceptionally complex process. It is reasonable to as- increased burden of the COVID‐19 pandemic, identifying protective sume that approach‐focused coping does not always enhance posi- factors to cope with and mitigate PSP‐specific mental health chal- tive affect and avoidant‐focused coping does not always enhance lenges is more urgent than ever. negative affect. Due to the trauma‐informed work environment and high stress In some cases, avoidance‐focused coping may provide time for that PSP encounter regularly, personal coping strategies are central recovery post‐event in a protective manner. Hence, the successful elements of PSP self‐care (Lanza et al., 2018). Coping is a broad adaptation may depend less on the specific process but rather the psychological concept defined as ‘efforts to prevent or diminish the ability to flexibly enhance or suppress emotional expression threat, harm and loss, or to reduce associated distress' related to a according to situational demands (Bonanno et al., 2004; Mayne & psychological stressor (Carver & Connor‐Smith, 2010, p. 685). His- Bonanno, 2001). Further, the effectiveness of specific emotion torically, Lazarus and Folkman (1984) were among the first to use the regulation strategies depends on the interaction of the features of a term ‘coping' to describe the cognitive and behavioural patterns used situation and the individual's personality characteristics regulating to manage stress—generally categorized as emotion‐focused or their emotions (Barrett & Gross, 2001; Kobylińska & Kusev, 2019). problem‐focused coping (Garcia, 2010; Lazarus & Folkman, 1984). Effective coping appears to depend on the congruence between the While the concept of coping has been long established, to date, there perceived stressor and an individual's chosen coping strategy, as is no universally accepted or formal clinical definition of coping. mediated by one's personal appraisal of the threat stressful event Coping is often operationalized as various strategies (i.e., behaviours, skills, or ways of regulating thoughts and emotions) for dealing with stressors. For PSP, psychological stressors could include (Anderson et al., 2002; Anshel, 2000). What remains unclear is identifying specific coping strategies that effectively mitigate the impact of PTSIs among PSP. occupational PPTEs and their associated emotional and cognitive ef- Higher rates of PTSI symptoms among PSP have been shown to fects. Strategies used to help PSP cope allow them to direct effort to negatively impact the quality of occupational performance and recognize and process physical or psychological stressors that cause interpersonal relationships, increase absenteeism, burnout and sleep distress, and then determine the best approach to address stressors difficulties, and contribute to early mortality (Anderson et al., 2002; that exceed one's immediate resources (Anshel, 2000; Krohne, 2002; Gerber et al., 2010; Lopez, 2011). The associated high costs of PTSI Lazarus & Folkman, 1984). These coping strategies are commonly have prompted several stakeholder organizations and occupational dichotomized with Fauerbach et al. (2009) defining coping strategies health policymakers to seek proactive approaches, such as imple- as self‐regulatory techniques that either confront the situation or menting mental health training programs to mitigate the impact of stressor (approach strategies) or avoid the situation or stressor PPTE on workers (Iacobucci, 2014; Weiss, 2019). Interventions (avoidance strategies). Many synonymous terms exist in the literature aimed at protecting PSP mental health have typically focused on to describe this dichotomy, such as positive, adaptive, engagement, building resilience and managing occupational stress while coping is and approach coping versus negative, maladaptive, disengagement, inconsistently measured, if at all. For example, several researchers and avoidant coping (Anshel, 2000; Skinner et al., 2003). have shown improved physiological stress responses following con- Seminal coping research defines approach coping as any strategy ditioning of the autonomic nervous system among police (Andersen that directly confronts a stressor and its related emotions (Moos & et al., 2018; Arble et al., 2017; Arnetz et al., 2009). Various other Schaefer, 1993; Skinner et al., 2003). Examples of approach coping types of organizational interventions show modest reductions in PTSI 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 614 symptoms (i.e., small effect sizes) that are time‐limited (Beshai & Carleton, 2016; Carleton, Korol et al, 2018c, Carleton et al. 2019b; McCreary, 2019), including online resilience training modules that have low adherence rates (Joyce et al., 2018, 2019). These findings are also apparent in trainee paramedics (Anderson et al., 2017; Vaughan et al., 2020) and nurses (Anderson, Black, Collins & Vaughan, 2019). Also, coping skills obtained through resilience training can be expected to deteriorate like other learned skills (Andersen et al., 2018; Anderson et al., 2017, 2019), meaning refresher programs are likely critical for maintaining gains. Whether due to ineffectiveness of the interventions themselves or a lack of consistent organizational support, the interventions mentioned above fail to identify effective strategies that support long‐term coping following PPTEs, which is particularly relevant for PSP. Given mounting evidence that stigma substantially inhibits care‐ seeking for mental health challenges in these populations (Carleton et al., 2019a, 2019b; Ricciardelli, 2018; Ricciardelli et al., 2018), occupational training that emphasizes adaptive coping to work‐ related exposures may be better suited for initial or basic training. While having social supports and tolerating uncertainty are critical to resilience and handling of stress, recent evidence suggests that these factors are also relevant to protecting PSP from adverse psychological outcomes following PPTE (Angehrn et al., 2020; Vig et al., 2020). However, there remains a gap in the literature surrounding which coping methods effectively mitigate PTSIs and FIGURE 1 PRISMA flow diagram promote mental health over time among PSP. language studies involving adult PSP (aged 18 and older) published between 1 January 2000, and 9 December 2019 that explored 2 | OBJECTIVES coping–whether in response to a discrete PPTE, or general exposure to PPTE due to their occupation as PSP. PSP were defined per the The current study was designed as a systematic literature review to CIPSRT glossary (2020) and keywords included: border services, identify published research on longitudinal coping outcomes among communications officials, corrections or correctional officers, PSP and evaluate changes in coping over time with a meta‐analysis. firefighter, paramedic, police, search and rescue, and emergency Results are presented to summarize the various methodological ap- services. Eligible outcomes included empirically derived, validated proaches (i.e., interventions, observational studies), durations, and psychological measures of coping, such as the Brief COPE outcomes evaluated in recent empirical repeated‐measures studies (Carver, 1997) and Ways of Coping Questionnaire (Folkman & of coping. The current results can help industrial, organizational, and Lazarus, 1988), as well as theoretically derived coping measures. occupational implement Eligible study designs included randomized control trials (RCT) and evidence‐based programming that effectively mitigates PTSI among quasi‐experimental studies (e.g., within‐subject pre‐post intervention PSP and others exposed to PPTE. or observational studies). stakeholders develop, evaluate, and Exclusion criteria included studies evaluating non‐PPTE‐related occupational stressors (e.g., work‐related demands, organizational 3 | METHODS stress), non‐peer‐reviewed theses or dissertations, non‐experimental designs (e.g., protocols), qualitative studies, and cross‐sectional (i.e., 3.1 | Eligibility criteria single timepoint) studies. The current systematic literature review procedures followed PRISMA guidelines (Liberati et al., 2009; Figure 1), and the search 3.2 | Search procedures strategy followed a population‐intervention‐comparison‐outcome (PICO) framework (Table 1). Given the vast heterogeneity in coping Boolean searches combining keywords of interest were conducted in terminology in the extant literature, for the purpose of this review, the following electronic databases: EMBASE, MEDLINE, PsycINFO, the terms ‘approach' and ‘avoidant' coping were used. Restricted PubMed and Web of Science. Searches were supplemented with review eligibility were limited to peer‐reviewed English‐ or French‐ hand‐searches of reference lists from relevant studies and earlier 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License - 615 DI NOTA ET AL. - TABLE 1 DI NOTA ET AL. PICO search strategy and search terms Domain Target Search Terms Population PSP Border services Communications officials Corrections or correctional Firefighter Paramedic Police Search and rescue Emergency services Officers Intervention Coping Coping Coping strategies Approach Avoidance or avoidant Problem‐focused Emotion‐focused Trial Pre‐post Comparison Control group (for intervention studies) Randomized control trial Outcome Coping measures Coping Strategies Inventory Coping strategy indicator Coping orientation to problems experienced Brief COPE Ways of Coping Questionnaire published review articles and reports. Following the searches, all ci- sex, role/position/rank, and years of employment. Intervention vari- tations were imported into Covidence—a web‐based systematic re- ables included repeated‐measures study design, and if an interven- view manager (Veritas Health Innovation, 2019). Two independent tion study, a description of the program's delivery and duration as reviewers (Paula M. Di Nota, Emily Kasurak) screened all results reported by study authors. Comparison variables included the type against the eligibility criteria, first by title and abstract, and then the and nature of the comparator group (e.g., waitlist control or within‐ full‐text article. All discrepancies were examined by a third reviewer subject design). Outcome variables of interest included validated (Gregory S. Anderson) for final decisions. Within Covidence, inter‐ psychological measures of coping (e.g., Brief COPE (Carver, 1997)) as rater reliability was measured using Cohen's kappa across the title/ well as outcomes related to theoretically supported forms of abstract and full‐text review stages, which were 0.69 and 0.75, approach coping, including social support (e.g., Social Support Scale respectively. Accordingly, this suggests a substantial agreement [Caplan et al., 1975]), and avoidant coping, including substance use, between reviewers on article selection (McHugh, 2012). To that end, thought suppression (White Bear Suppression Inventory [Wegner & all discrepancies were resolved with consensus between the two Zanakos, 1994]) and experiential avoidance (e.g., Acceptance & reviewers. Action Questionnaire [Hayes et al., 2004]). 3.3 | Data extraction 3.4 | Quality assessment Two reviewers (Paula M. Di Nota, Emily Kasurak) extracted data Study quality was appraised using the Newcastle‐Ottawa Scale independently from published full‐text reports of eligible articles. (Wells et al., 2019), which evaluates nine items across three domains: Population variables of interest included PSP occupation, sample size, selection, comparability, and outcome. Each item received a rating of and if provided, demographic information related to participant age, high, low, or unclear risk of bias. Each instance of a low risk of bias 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 616 counted as one point, for a total possible score of nine. Overall study firefighters, police officers), intervention category (e.g., psychological quality was operationalized using the total score: scores of 9 as ‘high interventions vs. physical activity such as leisure activity or physical quality', scores of 7 or 8 as ‘moderate to high quality', scores of 5 or 6 exercise), and study design (e.g., randomized controlled trial vs. as ‘moderate to low quality', and scores below five as ‘low quality'. within‐subject intervention and/or observational study). The robustness of our findings was assessed by conducting sensitivity analyses, such as comparing the effect sizes from the random‐effects and fixed‐ 3.5 | Synthesis of results effects model. To measure publication bias, funnel plot asymmetry was measured using Egger's test (Begg & Mazumdar, 1994). Meta‐ Statistical analyses were conducted in R studio version 3.5.3 (RStudio regression analyses were also performed to determine the impact of Team, 2020) using the meta package, which runs random‐effects the study's age and sex distribution on effect size. Given the expec- meta‐analysis models to pool effect sizes across studies. For inclu- tation that coping skills deteriorate over time (Vaughan et al., 2020), sion in the quantitative meta‐analysis, studies were required to report three post‐hoc meta‐regression analyses were performed by time‐ means, standard deviations, and sample sizes at the pooled study since event, the duration of treatment, and the time to follow‐up. endpoint for each outcome of interest (see Appendix A). Studies that reported standard errors were converted to standard deviations by multiplying the standard error by the square root of the sample size. 4 | RESULTS Across studies, there were only continuous outcomes (e.g., scores on instruments). Therefore, all effect sizes were pooled using Cohen's A total of 6769 studies were identified by the systematic review, and standardized mean differences (SMD, d) and their corresponding 95% 6429 unique studies after removing 340 duplicates. After title and confidence intervals (95% CI). According to Cohen's criteria abstract screening, 6096 records were removed, leaving 333 studies (Cohen, 2013; Faraone, 2008), SMD values of 0.2 were interpreted as for full‐text review. An additional 320 studies were excluded at the ‘small', 0.5 as ‘medium', and 0.8 or greater as ‘large'. full‐text stage for the following reasons: wrong study design (i.e., Given the heterogeneity in outcome measures across studies protocols, theses, reviews, commentaries, qualitative or cross‐ (Appendix A), composite outcome measures were created for sectional studies, n = 227), wrong outcomes (i.e., studies that did ‘approach coping' and ‘avoidant coping', based on the directionality of not report coping as an outcome measure, n = 49), wrong population the scores for a specific coping instrument. For example, an increase (n = 20), full‐text articles unavailable (n = 13), wrong intervention in any of the approach subscales of the Brief COPE (e.g., planning, (i.e., work satisfaction, n = 7), erratum (n = 2), duplicate (n = 1), non‐ humour and acceptance) indicated improved coping, whereas a English full‐text (n = 1). The current systematic review found 13 decrease in any of the avoidant subscales of the Brief COPE (e.g., eligible studies. Key study characteristics including quality assess- substance use, behavioural disengagement) also indicated better ment rating, participant summaries, study designs, intervention coping. The diversity in assessment instruments used across studies descriptions and durations (if applicable), evaluation periods, primary provided further justification for using the SMD to standardize effect outcomes and results were tabulated and are described below and sizes. As there were an insufficient number of studies (i.e., more than summarized in Table 2. three) reporting the same outcome at the same follow‐up period, all follow‐up durations were pooled within and across studies (e.g., Brief COPE at 6‐month and 9‐month follow‐up were pooled to a single 4.1 | Study characteristics follow‐up timepoint). For within‐subject cohort studies, effect sizes were calculated by measuring the difference between the baseline The 13 studies represented data from 1854 individuals. Police offi- and follow‐up scores on the instruments; for RCTs, effect sizes were cers were the most common PSP occupational group (n = 9), followed calculated by measuring the difference between the experimental by firefighters (n = 3) and rescue and recovery workers (n = 1). and follow‐up scores and control groups. For crossover RCT studies, Between‐subject RCTs (including cluster, parallel, and crossover) and only data from the first half of the study (i.e., before the crossover) within‐subject observational studies were the most common study were considered. design types (n = 6 each). For the intervention studies (n = 7), program durations ranged from a single 90‐min group session (Tuckey & Scott, 2014) to several‐day workshops (Ranta, 2009) or longer 3.6 | Assessment of heterogeneity and additional analyses weekly training sessions up to 32 weeks (Acquadro Maran et al., 2018). Follow‐up evaluations ranged from immediately following the intervention or PPTE (n = 4), 1 to 3 months (n = 5), 6 to Heterogeneity was quantified using the I2 statistic (Higgins & 12 months (n = 5), 24 to 28 months (n = 2), and one study at 10‐year Thompson, 2002) and forest plots, which are graphs depicting sum- follow‐up (de Terte et al., 2014). A single study with multiple follow‐ mary effect sizes across studies (Kang et al., 2016). Where possible, up durations would be included in more than one of the categories we explored for additional sources of heterogeneity using (e.g., Alghamdi et al., 2015 conducted pre‐, post‐intervention, 3‐ and pre‐specified 6‐month evaluations). subgroup analyses by PSP occupation (e.g., 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License - 617 DI NOTA ET AL. Police (80) India Firefighters (75) Australia Ranta, 2009* (low) Skeffington et al., 2016 (moderate‐high) 1 h/week × 4 weeks group sessions 3 × 1 h group sessions + homework versus 1 × 1 h session 3 h/week × 8 weeks 90 min × 4 sessions (over 3 weeks) 1.5 h/week × 32 weeks Intervention duration Outcomes Results Pre‐training, 6 months, 12 months follow‐ up Pre‐training, post‐ training Pre‐training, post‐ training Reduction in passive coping strategies immediately post‐ treatment, and sustained increase in social support. Changes in primary outcomes (PTSD, depression, anxiety) not sustained at follow‐up Significant post‐intervention increase in coping in MI group only. SDs not provided, author contacted Significant decrease in adaptive Brief COPE adaptive (active and maladaptive coping in coping, planning, positive both groups at 12‐month reframing, acceptance, follow‐up. Sustained increase humour, religion, emotional in perceived social support support, instrumental among the control group only support) and maladaptive subscales (self‐distraction, denial, venting, substance use, behavioural disengagement, self‐blame); SSQN Coping Behaviour Questionnaire Coping subscales of OSI (social Significant post‐intervention support, task strategies, logic, increases in social support, home/work relations, time task strategies, home/work management, involvement) relations, and involvement, and significant decreases in time management Pre‐training, post‐ Brief COPE active (planning, training, 3 months, religion, positive reframing) 6 months follow‐ and passive (behavioural up disengagement, substance abuse, self‐blame) subscales; SSS (family, friends, and GNGO subscales) 10 weeks pre‐training, Brief COPE (active coping, Increased adaptive coping and 3 months follow‐ emotional support, decreased maladaptive coping up instrumental support, positive post‐intervention overall. reframing, planning, humour, Less self‐distraction and more acceptance, religion, self‐ active coping following distraction, denial, substance physical intervention, use, behavioural opposite for wellness group disengagement, venting, self‐ blame subscales) Evaluations DI NOTA ET AL. 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License MAPS versus TAU MI versus RI Physical exercise versus WLC Police (20) Italy Fischetti et al., 2019 (moderate‐low) Physical exercise versus wellbeing classes NET versus WLC Police (105) Italy Intervention description Alghamdi et al., 2015 Firefighters (34) (moderate‐high) Saudi Arabia Acquadro Maran et al., 2018 (moderate‐low) Randomized control trials Population (n) country Summary characteristics of eligible studies yielded in systematic literature review (n = 13) Study (quality) TABLE 2 618 Police (11) USA Deputy marshalls (747) USA Intervention duration N/A SOICs versus Marshalls from other departments Approach‐avoidance coping intervention Pre‐training, 1 month follow‐up Evaluations N/A N/A Baseline (start of police training), 1‐ year, 10‐years follow‐up Baseline, 14 months, 28 months follow‐ up 2 h seminar + 10 week Pre‐training, post‐ intervention + 2 × 1 h training coaching sessions CISD versus stress management 90 min group CISD and education versus screening education sessions only (no treatment control) within three days of PPTE Intervention description Social support from colleagues predicted fewer PTSD symptoms and less psychological distress. Adaptive coping and support from colleagues predicted better physical health. Coping was evaluated at 10years follow‐up only. BRCS, SSS supervisor, colleague, family subscales (Continues) Increased social support coping, moderate to high physical activity, and self‐reported support from supervisors and coworkers related to lower STS. Denial and increases in past‐year alcohol and tobacco were related to higher STS. Demographic variables (i.e., having children) did not influence STS. Ms and SDs are not provided for coping outcomes, author contacted. No significant differences in either approach or avoidant coping post‐intervention Controlling for pre‐intervention scores, CISD was associated with significantly less alcohol consumption one‐month post‐intervention relative to the screening only condition, but not the education group Results COPE Scale (active, positive reinterpretation, social support, denial, planning subscales); separate self‐ reported scales for supervisory and colleague support, alcohol and tobacco use; physical exercise (IPAQ) CSAS (approach and avoidance subscales) Past week alcohol consumption Outcomes - 619 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License de Terte et al., 2014* Police (176) New (moderate‐low) Zealand Craun et al., 2014* (moderate‐low) Within‐subject observational studies Anshel & Brinthaupt, 2014 (moderate‐high) Within‐subject intervention studies Tuckey & Scott, 2014 Volunteer (moderate‐high) firefighters (67) Australia Population (n) country (Continued) Study (quality) TABLE 2 DI NOTA ET AL. Police and emergency response services (200) Canada Police officers (120) South Africa Iwasaki et al., 2002 (moderate‐high) Wasserman et al., 2019 (moderate‐low) N/A N/A N/A Intervention duration Baseline (start of police training), 6‐ month, 2‐year follow‐up Baseline, 1 months, 2 months follow‐ up 4–8 weeks, 6 months, 9 months, 12 months follow‐ ups Evaluations Ms and SDs are not reported for coping or social support outcome measures, the corresponding author deceased. Wishful thinking decreased at 12 mons, while problem‐focused and avoidant coping increased at 9 and 12 months. Increased optimism predicted greater problem‐focused and social support coping and less wishful thinking and avoidance coping, but relationships were not stable over time. Perceived social support was related to optimism and seeking social support as a coping behaviour. Results Planful problem‐solving, positive WCQ (confrontive coping, reappraisal and confrontive distancing, self‐controlling, coping strategies used more seeking social support, relative to seeking social accepting responsibility, support, escape avoidance, escape avoidance, planful and accepting responsibility. problem‐solving, and positive Significant reductions in reappraisal subscales) accepting responsibility and confrontive coping, and increases in planful problem‐ solving, positive reappraisal, and escape avoidance over time. SDs not provided, author contacted. Leisure coping positively related LCBS; LCSS; COPE Scale to short‐ and long‐term (problem‐focused, emotion‐ coping, stress, and physical focused, social support, and mental health outcomes acceptance, restraint, positive above and beyond general reframing, disengagement coping strategies subscales); immediate coping outcomes (coping effectiveness, satisfaction, stress reduction) WCQ (problem‐focused, wishful thinking, seeking social support, self‐blame, avoidance subscales); SSQ; LOT Outcomes DI NOTA ET AL. 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License N/A N/A Rescue and recovery N/A workers (159) USA Intervention description Dougall et al., 2001 (moderate‐low) Population (n) country (Continued) Study (quality) TABLE 2 620 Police officers (60) Australia Williams et al., 2010 (moderate‐low) N/A Intervention description Evaluations Baseline, 10‐12‐ month follow‐up Intervention duration N/A Results No differences in avoidance patterns at follow‐up, but increases in depressive symptoms. Thought suppression scores at baseline predicted depression at follow‐up. Outcomes AAQ (experiential avoidance), WBSI (thought suppression) Abbreviations: AAQ, Acceptance and Action Questionnaire; BRCS, Brief Resilience Coping Scale; CISD, critical incident stress debriefing; COPE, coping orientation for problem experiences; CSAS, coping style for acute stress; GNGO, governmental and non‐governmental organizations; IPAQ, International Physical Activity Questionnaire; LCBS, Leisure Coping Beliefs Scale; LCSS, Leisure Coping Strategy Scale; LOT, Life Orientation Test; M, mean; MAPS, mental agility and psychological strength; MI, Multidimensional Stress Management; Coping, and Relaxation Intervention; N/A, not applicable; NET, narrative exposure therapy; OSI, occupational stress indicator; PTSD, posttraumatic stress disorder; RI, Relaxation Only Intervention; SD, standard deviation; SOIC, sex offender investigation coordinator; SSQN, Social Support Questionnaire—short form; SSQ, Social Support Questionnaire; SSS, Social Support Scale; STS, secondary traumatic stress; TAU, training as usual; WBSI, White Bear Suppression Inventory; WCQ, Ways of Coping Questionnaire; WLC, waitlist control Note: Studies not included in meta‐analyses (n = 3) are marked with an asterisk (*) next to the authors' names. Studies are presented by study design: randomized control trials (RCTs, n = 6), within‐subject interventions (n = 1), and within‐subject observational studies (n = 6). Population (n) country (Continued) Study (quality) TABLE 2 DI NOTA ET AL. Of the 13 eligible studies, three were excluded from the meta‐ analysis for failing to report the means or standard deviations for their coping outcome measures (Craun et al., 2014; Ranta, 2009), for measuring coping at only one time point (de Terte et al., 2014), and for reporting only a global composite coping score (i.e., no separation of approach and avoidant subscales; Ranta, 2009). Requests for missing data were unanswered at the time of submitting the current review. Ultimately, ten studies were included in a quantitative meta‐ analysis. 4.2 | Meta‐analysis of approach coping While measures of approach coping appeared to improve at follow‐ up, the improvement was a small effect and did not reach statistical significance (d = 0.18, 95% CI [−0.05, 0.18], k = 10 studies, I2 = 0%; Figure 2). There were no significant subgroup effects noted by study design, PSP category, or intervention category. Meta‐ regression analyses for the impact of age, sex distribution, or time (time‐since event, duration of treatment, time to follow up) on study effect sizes were not significant. F I G U R E 2 Forest plot for random‐effects meta‐analysis on longitudinal approach coping among public safety personnel. CI, confidence interval; SMD, standardized mean difference F I G U R E 3 Forest plot for random‐effects meta‐analysis on longitudinal avoidant coping among public safety personnel. SMD = standardized mean difference; CI, confidence interval; SMD, standardized mean difference 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License - 621 - DI NOTA ET AL. FIGURE 4 Funnel plot for publication bias in (a) approach coping and (b) avoidant coping meta‐analyses F I G U R E 5 Quality assessment using the Newcastle‐Ottawa Scale. Full sample (n = 13 studies) summary of the strength of evidence from the systematic review 4.3 | Meta‐analysis of avoidant coping While avoidant coping measures appeared to 4.4 | Publication bias improve at follow‐up, the improvement was also a small effect and did not There was no evidence of publication bias for either approach or avoidant coping (Figure 4). reach statistical significance (d = −0.12, 95% CI [−0.27, 0.04], k = 7 studies, I2 = 0%; Figure 3). There were no significant subgroup effects noted by study design, PSP category, or 4.5 | Quality assessment intervention category. Meta‐regression analyses for the impact of age, sex distribution, or time on study effect sizes were not Quality assessment ratings for all studies in the current systematic significant. review are illustrated in Figure 5, and individual study ratings are 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 622 Low Low Low Low Low Low Low Low Low Alghamdi et al., 2015 High Anshel & High Brinthaupt, 2014 High de Terte et al., 2014 High High High Low Low High Dougall et al., 2001 Fischetti et al., 2019 High High Craun et al., 2014 Iwasaki et al., 2002 Ranta, 2009 Skeffington et al., 2016 Tuckey & Scott, 2014 Wasserman et al., 2019 Williams et al., 2010 High Low Low Low Low High Representativeness of the Selection of exposed cohort non‐exposed Individual quality assessment ratings (n = 13) Low Low Low Low High Low Low Low Low Low Low Low Low Ascertainment of exposure Low Low Low Low Low Low Low High High High Low Low Low Primary outcome not present at baseline High High Low Low High Low High High Low High High Low High High High Low Low High Low High Low High Low Low Low High Comparability of Comparability of cohorts (I) cohorts (II) Low Low High Low Low Low Low Low Low Low Low Low Low Low Low Low Low High Low High Low Low Low Low Low Low Assessment of Duration of outcome follow‐up Low High Low High High High Low Low High Low Low High Low Adequacy of follow‐up - 623 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Acquadro Maran et al., 2018 Study TABLE 3 DI NOTA ET AL. - DI NOTA ET AL. reported in Table 3. Overall, no studies were of ‘high quality'. Five unvalidated self‐report measures of past week alcohol consumption, studies were ‘moderate to high quality' (Alghamdi et al., 2015; Anshel which could be prone to individual reporting biases (e.g., memory & Brinthaupt, 2014; Iwasaki et al., 2002; Skeffington et al., 2016; errors, desire to respond in a favourable way that minimized stig- Tuckey & Scott, 2014), seven were of ‘moderate to low quality' matized attitudes or behaviours). Except for two RCTs (Fischetti (Acquadro Maran et al., 2018; Craun et al., 2014; de Terte et al., 2014; et al., 2019; Ranta, 2009), all remaining studies provided sufficient Dougall et al., 2001; Fischetti et al., 2019; Wasserman et al., 2019; time following a PPTE or participation in a PTSI mitigation service or Williams et al., 2010), and one study was ‘low quality' (Ranta, 2009). program before collecting outcome measures, resulting in low risk of bias ratings based on time. There were six out of 13 studies that were rated as high risk for failing to provide an analysis of baseline 4.5.1 | Selection measures or demographic variables between participants lost at follow‐up and those who completed follow‐up measures; however, Regarding individual study quality assessment criteria, all but two Tuckey and Scott (2014) did apply appropriate statistical analyses (Skeffington et al., 2016; Tuckey & Scott, 2014) of the studies (i.e., multilevel hierarchical modelling) to account for post‐ included in the current review did not demonstrate that their sample intervention attrition. was representative of the larger population of workers concerning demographic variables such as sex, average age, or years of service, limiting the generalizability of their results. All studies were rated at 5 | DISCUSSION a low risk of bias regarding selection of the non‐exposed cohort, which was either randomly chosen from the same population in the Amplified by the global coronavirus pandemic, identifying discrete case of RCTs, or not applicable for single‐sample intervention and behaviours, skills, and strategies to cope with trauma to reduce observational study designs. All but one study (Ranta, 2009) provided adverse health outcomes is more urgent than ever. The current a clear indication that participants were exposed to (or participated systematic review identified 13 repeated‐measures studies of in) a PTSI intervention, or PPTEs as measured by traumatic exposure approach and avoidant coping among 1854 police officers, fire- questionnaires or active duty fieldwork preceding each follow‐up fighters, and rescue and recovery workers. Effect sizes (Cohen's d) at evaluation. Three studies received a high‐risk rating for failing to follow‐up were described in 11 studies, and meta‐analyses revealed provide baseline scores to demonstrate that the outcome of interest small (d < 0.2) but non‐significant improvements in approach and (i.e., high levels of adaptive coping or low levels of avoidant coping) avoidant coping across studies. Findings were affected by significant was not present at the start of the study (Craun et al., 2014; de Terte heterogeneity in study design, exposure to potentially traumatic et al., 2014; Dougall et al., 2001). events, PSP population, outcome measures and definitions of coping, intervention and follow‐up types and durations. To that end, extant literature is unclear regarding the long‐term 4.5.2 | Comparability effectiveness of various coping strategies employed by PSP following exposure to work‐related PPTE. The current findings can inform the Most studies (eight of 13) were deemed at a high risk of bias for development and evaluation of organizational training programs that failing to control for, or account for, the most crucial factor in the effectively promote sustained adaptive coping for PSP and mitigate study design or analysis—the presence of a PTSI or diagnosable PTSIs. mental disorder at the time of the study—which would substantially Although the overall risk of publication bias was deemed small, bias the outcome of intervention (i.e., evaluating the effectiveness of the quality of the individual studies was low to moderate. Most a PTSI mitigation service) or observational studies (i.e., changes in studies were at a high risk of reporting bias concerning evaluation of coping over time or relationship to other psychological or health the representativeness of study samples to the broader population. factors). Similarly, six out of 13 were at a high risk of bias for failing to More than half of the studies also failed to assess or control for the control for an additional factor in their study design or analysis, such presence of a PTSI or mental disorder, which would likely impact as participant sex, age, or years of service, which have been statis- coping outcomes and confound investigations of PTSI program tically significantly associated with PSP mental health outcomes effectiveness. Six of the 13 studies also failed to account for sec- (Carleton et al., 2018a). ondary factors in their analyses that would affect coping (i.e., sex, years of service, exposure to occupational PPTEs), and six studies failed to compare baseline or demographic data between participants 4.5.3 | Outcome lost to follow‐up and those retained in the study. All but one study was rated at low risk of bias regarding assessing provides study outcomes based on empirically validated self‐report coping approach (n = 10) and avoidant (n = 7) coping measures at follow‐up tools. Tuckey and Scott (2014) received a high risk of bias rating for (see Appendix A), regardless of whether participants were exposed using revised versions of previously validated measures and to a PTSI mitigation intervention program (n = 7) or part of an Evaluation of study outcomes with quantitative meta‐analyses modest evidence for improvements in aggregated 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 624 observational study (n = 4). However, meta‐analytic results did not is a need to understand crucial ingredients, mechanisms of change, or reach statistical significance for either approach or avoidant coping. barriers to maintaining post‐intervention gains in psychological Consistent with previous literature on post‐training improvements in functioning (Anderson et al., 2020) and cross‐fertilizing insights from PTSI among PSP (Beshai & Carleton, 2016; Carleton et al., 2019b; qualitative and quantitative studies (Coyne & Racioppo, 2000). McCreary, 2019), improvements in coping skills have small effect For the current review and analysis, we operationalized sizes and diminish over time. Further, most PSP coping studies do not approach coping as all of the positive, adaptive behaviours, skills, and measure coping as the primary study outcome, but more commonly strategies that individuals can employ to improve psychological include coping as an additional measure of broader psychological health and functioning. Avoidant coping was operationalized by health and functioning. The vast majority of relevant investigations negative, maladaptive behaviours, skills, and strategies that can yielded by our systematic literature review (n = 227, see Figure 1 and degrade psychological health and functioning (Anshel, 2000; Carver Table 1 for eligibility criteria) included qualitative or cross‐sectional & Connor‐Smith, 2010; Moos & Schaefer, 1993; Skinner et al., 2003; studies (i.e., evaluating coping and other measures at a single point see Appendix A). Subscales representing approach coping strategies in time). Of these studies, coping was often investigated as a medi- are far more varied than avoidant coping and range from cognitive ating or moderating variable between psychological outcomes and and emotional processing strategies (e.g., positive reframing, accep- other factors, including occupational stressors, PTSI symptoms, and tance, emotion‐ and problem‐focused coping) to concrete behaviours burnout (Ângelo & Chambel, 2014; Chang et al., 2008; Isenhardt related to occupational stress (Occupational Stress Indicator coping et al., 2019; Ryu et al., 2020; Violanti et al., 2018). For the current subscale, Cooper et al., 1988). Iwasaki presents a series of studies sample of eligible longitudinal studies of PSP coping (Table 2, n = 13), examining the role of leisure in promoting adaptive coping, focussing seven investigated the impact of an intervention on coping. Only one on PSP (Iwasaki, 2003; Iwasaki et al, 2002, 2005). Accordingly, of these interventions was explicitly aimed at improving coping approach coping strategies are rooted in various theoretical frame- (Anshel & Brinthaupt, 2014), four aimed to train various forms of works, further complicating the identification of a unified definition. stress management, emotion regulation, or psychological strength The inconsistent evaluation of specific approach coping strategies (Alghamdi et al., 2015; Ranta, 2009; Skeffington et al., 2016; Tuckey also precludes the identification of an optimal strategy or behaviour & Scott, 2014), and two aimed to improve psychological functioning that best promotes long‐term psychological health and mitigates via physical exercise and strength conditioning (Acquadro Maran PTSIs among PSP. et al., 2018; Fischetti et al., 2019). Coping was the primary outcome In contrast, avoidant coping strategies are more narrowly measure in all but two investigations, which primarily evaluated post‐ operationalized by negative, maladaptive behaviours (e.g., with- training improvements in PTSD and other PTSI symptoms (Alghamdi drawal, avoidance, disengagement, venting, thought suppression) and et al., 2015; Tuckey & Scott, 2014). strategies (e.g., self‐blame, denial, self‐distraction). In the general The literature identified presently lacks a clear, unified definition population, higher avoidant coping levels predict increased risk of of coping, which is also not a clinically validated construct for PTSIs self‐harm, suicidal ideation, and higher alcohol consumption (Nielsen (CIPSRT, 2020). Accordingly, we found significant inconsistency in et al., 2016; Wills & Hirky, 1996; Woodhead et al., 2014). Among coping outcome measures used across studies and inconsistent PSP, substance abuse has been reported as a common form of aggregation of various subscales to operationalize approach and coping with occupational PPTEs (Martin et al., 2017; Ménard & avoidant coping (see Appendix A). The Brief COPE (Carver, 1997) Arter, 2013), with an estimated 5.9% of Canadian PSP surveyed by was used most often (three of 13), with distinct (Acquadro Maran Carleton et al. (2018a) screening positive for risky alcohol con- et al., 2018) and aggregated subscales defined as both ‘active' and sumption as evaluated by the Alcohol Use Disorders Identification ‘passive' (Alghamdi et al., 2015) or ‘adaptive' and ‘maladaptive' Test (AUDIT, Babor et al., 2001). Di Nota et al. (2020) also reveal (Skeffington et al., 2016). Different subscales of the Coping Orien- that risky alcohol use increases the risk for suicidal ideation among tation for Problem Experiences (COPE, Carver et al., 1989) scale police when controlling for age and sex. Four studies in the current were used in two studies (Craun et al., 2014; Iwasaki et al., 2002). review evaluated substance use but aggregated this outcome with However, Craun et al. (2014) failed to report the means and standard other avoidant subscales (Acquadro Maran et al., 2018; Alghamdi deviations for their coping outcomes and were thus excluded from et al., 2015; Skeffington et al., 2016) or failed to evaluate substance the present meta‐analysis. Therefore, inconsistencies in outcome abuse with empirically validated screening tools like the AUDIT measures and data reporting preclude a more thorough analysis of (Tuckey & Scott, 2014). Alcohol or substance abuse has been oper- long‐term changes in coping among PSP. This finding is also consis- ationalized as a PTSI (CIPSRT, 2020), a form of maladaptive coping tent with a longstanding controversy in coping measurement dis- (Brief COPE subscale, Carver, 1997), and is a diagnosable disorder cussed by Coyne and Racioppo (2000), who contrast differences (ICD‐10: World Health Organization, 1993; DSM‐5: American Psy- between descriptive studies that employ coping checklists from in- chiatric Association [APA], 2013). As with other coping strategies terventions that aim to improve psychological functioning and like social support, these outcomes possess their own stand‐alone adaptation by enhancing coping. While measuring coping in the latter definitions and theoretical frameworks. This range of operationali- context provides evidence of an intervention's efficacy, these are zation further contributes to the lack of a unified definition of often potentially misleading correlational studies. To that end, there coping. 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License - 625 DI NOTA ET AL. DI NOTA ET AL. Social support is reported in the current studies as both an Ultimately, another significant limitation of this review was the approach coping subscale (COPE) and a distinct outcome measured low yield of studies, which required collapsing of several moderators by various validated assessment scales (e.g., Social Support Scale by of coping in order to facilitate a meta‐analysis. For example, while Caplan et al., 1975; Social Support Questionnaire—Short Form by pooling all the follow‐up periods made computational sense given the Sarason et al., 1987). Social support is theoretically and conceptually low study yield, this impacted the interpretation of the findings. similar to approach coping, such that increased support‐seeking and Pooling all follow‐up times is especially problematic because this camaraderie buffers the adverse psychological and physical effects of review aimed to examine longitudinal data, and this strategy means PPTE (Charuvastra & Cloitre, 2008). However, occupational cultures that the meaningful variability in the longitudinal data is lost. To that in the public safety professions often stigmatize emotional support end, post‐hoc meta‐regression analyses by time‐since event, duration seeking (Britt & McFadden, 2012; Ricciardelli, 2018). There is of treatment, and time to follow‐up were conducted and did not promising evidence that resilience and mental health training can identify any statistically significant association with either adaptive diminish stigma to a greater extent than PTSI symptoms (Carleton or approach cooping. As coping to a specific event would be predicted et al., 2019b). Both perceived and actual social support promote to decrease as time lapsed, the time of coping measurement is PSP's mental health outcomes (Prati & Pietrantoni, 2010). PSP important—and may have been overlooked by our decision to pool reportedly seek social help from family and friends relatively more follow‐up outcomes. than supervisors or seek professional assistance (Carleton Subgroup and meta‐regression analyses were performed to et al., 2019b). Therefore, the development of resources to support examine the impact of some key moderators on the effectiveness of PSP spouses, families, and Allies would also indirectly contribute to coping, such as the type of coping scale used, the time since the the holistic promotion of PSP wellbeing. stressor, intervention length, and time since intervention. However, As there were no clearly effective strategies to enhance coping these analyses were compromised by the low study yield for any strategies in any PSP population, the review findings suggest that this individual moderator variable. For example, only a few of the studies remains a much‐needed area for future research. Limited and involved a referent event (e.g., exposure to a critical incident), while inconsistent study designs preclude more conclusive recommenda- most others measured generalized coping. We also considered mul- tions for specific coping strategies or training approaches. Future tiple public safety personnel professions (e.g., firefighters, police of- investigations of coping among PSP and evaluations of intervention ficers, peacekeepers). Similarly, multiple coping scales were pooled program effectiveness should consistently operationalize and eval- across studies—with some empirically derived, others theoretically uate PTSI and coping outcomes to further clarify the relationships derived, and a few were not specifically designed to measure coping. between them. The meta‐analysis performed used a SMD, which allows studies to be pooled that measure the same outcome (e.g., ‘coping') but in different ways. With that said, there is still a significant amount of residual 5.1 | Limitations heterogeneity in terms of these measurements, and statistical accommodations can only adjust for so much. Hence, it is possible that Study limitations may included the search strategy and criteria pro- stronger effect sizes may be found based on the type of coping scale, cess (Table 1), which restricted studies for inclusion to English‐ and referent event, time since the traumatic exposure, and the inter- French‐language studies published after 2000 from five indexed vention length and follow‐up duration; however, the present meta‐ electronic databases. Despite a relatively high number of search re- analysis may have been underpowered to find these differences in sults (n = 6769), less than 1% of studies yielded by the current sys- the present study. Finally, the decision to categorize coping as tematic literature review directly evaluated coping in PSP at more ‘approach' or ‘avoidant' should not be thought of as ‘positive' or than one time point. Accordingly, the main limitation of the present negative'. As coping strategies are not inherently good or bad, the meta‐analysis is the high heterogeneity of outcome measures and context in which these strategies are used is what is most important. operational definitions of coping across studies (see Appendix A). For instance, problem‐focused coping may worsen some outcomes, The design of eligible studies was also highly variable and limited, while denial may improve some results (at least in the short‐term). with just over half of studies investigating the long‐term effects of For these reasons, there is a need to standardize future studies a psychological intervention or training program compared to that investigate and seek to improve PSP's long‐term coping the remaining longitudinal within‐subject observational studies. outcomes. Geographical variability of study samples also makes generalizability difficult, as PPTEs and coping strategies used in one political, cultural, social, economic, and epidemiological context may not be relevant, 6 | CONCLUSIONS applicable, or practical elsewhere. Nevertheless, the substantial impact of PPTEs on PSP health and functioning is broadly accepted. There is an urgent need to identify effective and adaptive coping There is a need to consider and identify effective coping strategies to strategies that can effectively mitigate the adverse psychological mitigate PTSIs for these at‐risk workers to minimize personal, social, effects of traumatic occupational exposures, especially during the and organizational costs. current coronavirus pandemic. The current systematic review and 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License - 626 meta‐analysis yielded 13 relevant peer‐reviewed studies that measured PSP coping at more than one time point. Significant heterogeneity in study design, duration, coping measures, and strength of research evidence was found across studies. Consistent with previous evidence, improvements in approach and avoidant coping outcomes were of small and non‐significant effects, suggesting that the utilization of effective coping strategies and associated psychological benefits are short‐lived. Through the compilation of various definitions of coping and identification of practical study limitations, the current synthesis can inform future high‐quality research in PSP populations. A C K N O WL ED GE M EN T S The authors have no known conflicts of interest to declare. This research is supported by funds awarded to G. Anderson from the Canadian Institutes of Health Research (Team Grant: Mental Wellness and Public Safety Team Grants, #165543), who was Dean of Applied Research and Graduate Studies at the Justice Institute of British Columbia at the time of receiving funding. Data utilized for the meta‐analysis can be supplied upon request from the corresponding author. C O N F LI C T O F I N T E R ES T The authors have declared that they have no conflict of interest. A U TH O R C O N TR IB UT I O N S Study conception and design: Gregory S. Anderson, Dianne Groll; Data acquisition: Paula M. Di Nota; Data analysis and interpretation: Paula M. Di Nota, Emily Kasurak, Anees Bahji; Manuscript writing: Paula M. Di Nota, Emily Kasurak, Anees Bahji; Manuscript revisions (theoretical and technical): Dianne Groll, Gregory S. Anderson. D A TA A V AIL A B IL I T Y S T A T EM EN T This review used secondary data which is freely available within publications reviewed. For more information, please contact the authors. O R C ID Paula M. Di Nota Anees Bahji https://orcid.org/0000-0003-4282-6129 https://orcid.org/0000-0002-3490-314X REFERENCES Acquadro Maran, D., Zedda, M., & Varetto, A. (2018). Physical practice and wellness courses reduce distress and improve wellbeing in police officers. International Journal of Environmental Research and Public Health, 15(4), 578. https://doi.org/10.3390/ijerph15040578 Alghamdi, M., Hunt, N., & Thomas, S. (2015). The effectiveness of narrative exposure therapy with traumatised firefighters in Saudi Arabia: A randomized controlled study. Behaviour Research and Therapy, 66, 64–71. https://doi.org/10.1016/j.brat.2015.01.008 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author. Andersen, J. P., Di Nota, P. 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M., Kasurak, E., Bahji, A., Groll, D., & Anderson, G. S. (2021). Coping among public safety personnel: A systematic review and meta–analysis. Stress and Health, 37(4), 613–630. https://doi.org/10.1002/smi.3039 Meta‐analytic outcomes. List of coping outcome categories and specific measures included in the meta‐analysis Outcome category Specific measures included Direction Approach coping 1. Brief COPE: Planning, religion, positive reframing, active coping, emotional support, instrumental support, humour, acceptance subscales 2. Coping orientation for problem experiences (COPE): Problem‐focused, social support, emotion‐focused, acceptance, restraint, positive reframing subscales 3. Ways of coping Questionnaire: Seeking social support, planful problem solving, positive reappraisal, accepting responsibility 4. Coping Style for acute Stress: Approach subscale 5. Life orientation test 6. Leisure coping beliefs Scale 7. Leisure coping Strategy Scale 8. Social Support Scale (Jaber, 2012): Family, friends, GNGO subscales 9. Social Support Questionnaire—Short form (Sarason et al., 1987) 10. Occupational Stress Indicator coping subscales: Social support, task strategies, logic, home/work relations, time management, involvement Higher is better Avoidant coping 1. Brief COPE: Behavioural disengagement, substance abuse, self‐blame, denial, self‐ distraction, venting subscales 2. Coping orientation for problem experiences (COPE): Disengagement subscale 3. Ways of coping Questionnaire: Confrontive coping, escape‐avoidance 4. Coping Style for acute Stress: Avoidance subscale 5. Acceptance and action Questionnaire 6. White bear Suppression Inventory 7. Past week alcohol consumption Lower is better 15322998, 2021, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/smi.3039 by Cochrane Canada Provision, Wiley Online Library on [08/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 630