Supporting the well-being of nurses, paramedics, and firefighters during external crises by managing workload: an umbrella review

Abstract

Support is needed for the well-being of nurses and first responders in external crises. We aimed to synthesize the evidence between workload management strategies and well-being of nurses, paramedics, and firefighters during external crises in an umbrella review. The data sources OVID Medline, APA PsycInfo, CINAHL, Web of Science and the Cochrane Library were searched between 1.1.2013−20.6.2023. Two independent reviewers assessed the eligibility of the publications and conducted the data extraction and narrative synthesis. The search identified 1,073 references on nurses and 182 on paramedics and firefighters. Of the 62 full texts, 16 systematic reviews on nurses were included, and of the 13 full texts on paramedics and firefighters, two systematic reviews were included, making a total of 18 systematic reviews. The quality of the publications was predominantly good (83%). Both employee and work-directed strategies were beneficial in supporting employee well-being during external crises. Proactive practical skills training and psychological interventions were found as the most promising employee-directed strategies. The corresponding work-directed strategies were effective communication, providing useful information and adequate working conditions, supportive leadership, and peer support. To support well-being of nurses and first responders during external crises, workload management strategies need to be proactively planned in workplaces.

Background

Prior to the COVID-19 pandemic, there was an estimated global shortage of six million nurses¹⁾, and the shortage was exacerbated by the increase in workload caused by the pandemic²⁾. Similarly, first responders such as paramedics and firefighters suffer high turnover rates due to work-related stress and high workload³⁾. The COVID-19 pandemic demonstrated the necessity to provide support for employee well-being during external crises and exceptional circumstances, such as pandemics, natural disasters, and calamities (hereafter referred as external crises) across a range of occupational sectors.

The support is particularly relevant for health care employees and first responders, who are among those most exposed to such situations at work. There is ample evidence of the impact of external crises on employees’ well-being and mental health. For example, the prevalence of mental health problems (e.g., anxiety, depression, distress) increased among health care employees and first respondents during the COVID-19 pandemic^{4,5,6,7,8,9,10,11)}. In addition, COVID-19 studies have reported that health care employees often experience somatic symptoms, such as physical exhaustion^{12, 13)}.

An obvious reason for impaired employee well-being during external crises is the increased workload due to the intensification of psychosocial, physical, and worktime related factors. The stress-strain model^{14, 15)} provides an appropriate framework for considering strategies to manage the workload faced by employees during external crises. According to this model, workload arises when the employee is exposed to workload factors. This means that workload can be managed both by adjusting working conditions (e.g., working arrangements and methods) and by strengthening employees’ resources (e.g., competence, coping mechanisms for stress, physical work capacity), for example, through training and education.

Based on studies on distress and other negative effects of external crises on employee well-being during external crises, there is an urgent need to implement workload management strategies (WMSs)^16,17,18). The proposed work-directed WMSs include social support from colleagues, managers, and the organization, provision of appropriate personal protective equipment (PPE), ergonomic shift schedules, and improvements in workplace infrastructure^{16, 17, 19)}. Corresponding employee directed WMSs include training, increased screening for mental health problems, and psychological and lifestyle interventions^{7, 16, 17, 19)}.

In the wake of the COVID-19 pandemic, numerous studies have addressed the psychological well-being and distress of frontline employees, particularly those in the healthcare sector, including paramedics (e.g.,^{5, 18, 20,21,22,23)}). However, the evidence is based on mainly cross-sectional original studies^{5, 20, 21, 23)}. Strategies are needed to support employees’ well-being during crises, and this umbrella review aims to synthesize what is known about the association between workload management strategies and employees’ well-being in crises. As the ultimate aim of this umbrella review is to provide evidence-based recommendations for workplaces, it focuses on WMSs where the workplace plays an important role as a provider. The review focuses on nurses, paramedics, and firefighters, which are occupational groups directly exposed to and working together during external crises. These professionals are also crucial to ensuring security of supply, making their work essential to public safety and internal security.

Methods

Design

This study is an umbrella review on systematic reviews.

Selection criteria

The following selection criteria were used to screen the potential systematic reviews for this systematic review: 1) nursing staff, firefighters and/or paramedics as target population (s) but not necessarily limited to these occupations (e.g., reviews on first responders including paramedics or firefighters or both are eligible), 2) the outcomes are related to employees’ work ability, well-being, health, stress, recovery, resilience, and/or job-related outcomes (e.g., job satisfaction, job performance), 3) examines either a) associations between work or employee-directed strategies aimed at managing workload and the selected outcomes or b) the effectiveness of these strategies in improving the selected outcomes, 4) focuses on external crises, 5) is a systematic review (i.e. provides details of a systematic search strategy including databases, search terms and filters, inclusion and exclusion criteria, and thus allowing rapid systematic reviews and systematic scoping reviews to be accepted), 6) is published in English, 7) is available in electronic full text format and 8) was published between 1.1.2013–20.6.2023. Correspondingly, systematic reviews that only studied students or marginal part-time employees or included emergency situations that are part of everyday work (e.g., everyday work of emergency department personnel), or included workload management strategies or interventions where the workplace did not play a role or focused on post-crisis strategies or interventions (e.g., rehabilitation after an external crisis), and protocol papers were excluded.

Search methods

The databases OVID Medline, APA PsycInfo, CINAHL, Web of Science, and the Cochrane Library were searched from 1.1.2013 until 20.6.2023. The search strategy is described in Table 1.

Table 1. The search strategy.

Search string category	Nursing staff	Firefighters and paramedics
Participants	(nurse* or nursing or health care worker* or health care staff) AND	(firefighter* or fire fighter* or fire-fighter* or paramedic* OR emergency medical service* OR first responder*) AND
Emergency	(pandemic* or epidemic* or COVID-19 OR COVID19 or cris* or emergenc* or disaster* or calamit* or catastroph* or mass casualty incident* OR conflict* OR attack*) AND	(pandemic* or epidemic* or COVID-19 or COVID19 OR cris* or emergenc* or disaster* or calamit* or wildfire* or wildland fire* OR conflict* OR attack* or mass casualty incident or heatwave OR catastroph* OR conflict* OR attack* OR terror*) AND
Interventions	(intervention* or training or education or campaign* or program* or simulat* or strateg* or mitigation or management or defusing* or debriefing* or promotion or countermeasure* or guideline* or regulat*) AND	(intervention* or training or education or campaign* or program* or simulat* or strateg* or mitigation or management or defusing* or debriefing* or promotion or post critical incident seminar* or critical incident stress management or countermeasure* or guideline* or regulat* or cooling or hydration) AND
Outcomes	(well-being or wellbeing or recovery or recuperation or detachment from work or workload or strain or fatigue or sleepiness or alertness or vigilance or stress or distress or anxiety or fitness or physical work capacity or physical capacity or physical performance or functional capacity or sleep or circadian disruption* or circadian misalignment or burnout or exhaustion or depression or musculoskeletal or pain or disorder* or disease* or symptom* or work-life balance or work-life conflict or work-life interface or work-family balance or work-family conflict or work-family interface or health or resilience or work ability or performance or cognitive or near miss* or human error* or human factor error* or safety incident* or safety implication*)	(well-being or wellbeing or recovery or recuperation or detachment from work or workload or strain or fatigue or sleepiness or alertness or vigilance or stress or distress or anxiety or fitness or physical work capacity or physical capacity or physical performance or functional capacity or sleep or circadian disruption* or circadian misalignment or burnout or exhaustion or depression or musculoskeletal or pain or disorders or disease or symptom* or work-life balance or work-life conflict or work-life interface or work-family balance or work-family conflict or work-family interface or health or resilience or work ability or dehydration or performance or cognitive or near miss* or human error* or human factor error* or safety incident* or safety implication*)

Study selection and data extraction

Using Covidence (Covidence Systematic Review Software, 2020 Veritas Health Innovation, Melbourne, Australia), two independent reviewers (KK, MSa) reviewed the assessed study eligibility and extracted the data concerning systematic reviews on nurses. Similarly, but separately, two independent reviewers (JH, PS) reviewed the assessed study eligibility and extracted the data concerning systematic reviews on paramedics and firefighters. In case of any disagreements between the two reviewers in either of the two pairs, they would have been resolved with a third reviewer (SM on nurses and AP on paramedics and firefighters), but this phase was never needed.

The Covidence was used for screening and selection of studies. The data extraction was conducted utilizing the Joanna Briggs Institute (JBI) Data Extraction Form for Review for Systematic Reviews and Research Syntheses²⁴⁾. After the data extraction (MS and KK for the reviews on nurses and JH and PS on paramedics and firefighters, a third reviewer (PS for nurses, KK for paramedics and firefighters) cross-checked the tabulated results.

Quality appraisal

The JBI Critical Appraisal Instrument for Systematic Reviews was used for the quality appraisal²⁵⁾. The researchers conducting the appraisal discussed each specific critical appraisal checklist item before two reviewers independently conducted the appraisals (KK and MSa for the studies on nurses and JH and PS for the studies on paramedics and firefighters). Two of the 11 items were decided to be definite, i.e., other than “yes” as an answer for the questions “Is the review question clearly and explicitly stated?” and “Were the inclusion criteria appropriate for the review question?” would lead to exclusion of that study after the quality appraisal.

Data synthesis

The data synthesis was narrative.

Results

Search outcomes

The search yielded a total of 1,255 records after duplicates were removed, of which 1,073 were on nurses and 182 on paramedics and firefighters (Fig. 1). The abstract review in the nursing resulted in 62 eligible articles for the full-text review, of which 46 articles were excluded and 16 were included in the final review. The abstract review of the paramedic and firefighter studies identified 13 articles eligible for the full-text review, which subsequently reduced the number of articles by 11 to the final number of two reviews. Altogether 18 systematic reviews were included in this study.

Fig. 1.

The PRISMA flow diagram of study screening and selection process for nursing staff (on the left) and paramedics and firefighters (on the right).

Study characteristics

Tables 2 and 3 summarize the included systematic reviews in terms of study and search details, critical appraisal and analysis.

Table 2. Characteristics of the included systematic reviews: study and search details.

First author’s name, publication year, and reference	Objectives	Participants/target groups	Setting/context	Workload management strategies	Sources searched	Range (yr) of included studies	Number of included studies	Country of origin of the included studies
Baetzner et al. 202237)	To identify which disaster training methods are used and what training methods are effective in preparing medical first responders for disasters	Medical first responders (paramedics, emergency medical technicians, physicians, nurses, students)	Natural disasters, mass accidents, and human conflicts	Traditional (e.g., lectures, real-life scenario training) and technology-based (e.g., computer-based learning, virtual and mixed reality) disaster training interventions	PubMed, Web of Science	2010–2021	55	Australia, Azerbaijan, China, Germany, Indonesia, Iran, Israel, Italy, Japan, Malaysia, South Africa, South Korea, Spain, Sweden, Taiwan, Thailand, Turkey, UK, USA
Boone et al. 202334)	To examine how factors associated with COVID-19 affected the well-being and safety of nurses and to review interventions which may promote nurses’ mental health during crises	Nurses	COVID-19 pandemic	Interventions promoting nurses’ mental health during crises	CINAHL, Cochrane, PubMed, Scopus	2020–2021	17	Canada, China, Ethiopia, Iran, Jordan, Oman, Philippines, South Korea, USA
Curtin et al. 202233)	To investigate resilience among health care workers during pandemics	Health care workers	Pandemics (COVID-19, H1N1, MERS, EBOLA, and SARS)	Collegial support, effective communication by managers and organization, practical support from organization (staffing, training, PPE), and formal psychological support	CINAHL, Embase, MEDLINE, PsycInfo, Scopus, Web of Science	2005–2022	121	Australia, Austria, Bangladesh, Brazil, Canada, China, Denmark, Hong Kong, India, Iran, Ireland, Israel, Italy, Japan, Jordan, Kenya, Malawi, Netherlands, New Zealand, Nigeria, Norway, Philippines, Qatar, Romania, Sierra Leone, Singapore, South Korea, Spain, Sri Lanka, Sweden, Switzerland, Taiwan, Turkey, UK, USA
De Brier et al. 202026)	To identify the risk and protective factors for mental health outcomes in health care workers during coronavirus pandemics	Health care workers	Coronavirus pandemics (SARS, COVID-19, MERS)	Clear communication and support from the organization	Embase, MEDLINE, PsycINFO	2004–2020	33	Canada, China, Hong Kong, Singapore, South Korea, Taiwan
Ding et al. 2022 22)	To study the effects of coping methods on psychological well-being among health care workers during COVID-19	Frontline health care workers	COVID-19 pandemic	Online interventional (ambulatory and mindfulness-based stress reduction) programs, e-aid CBT, and PsyCovidApp-video-based programs	Cochrane Central Database, PubMed	2021–2022	7	China, Iran, Spain, Turkey, USA
Labrague 202127)	To examine resilience, coping behaviors and social support among health care workers during the coronavirus pandemic	Health care workers	COVID-19 pandemic	Organizational and supervisorial social support	CINAHL, MEDLINE, PsycINFO, PubMed, Scopus	2020–2021	31	China, Egypt, Israel, Italy, Pakistan, Palestine, Philippines, Spain, Turkey, USA
Labrague et al. 201838)	To explore nurses’ preparedness for disaster response	Nurses	Disasters	Disaster training or courses, awareness and execution of workplace disaster plans, strategies to enhance disaster preparedness	CINAHL, MEDLINE, PsycINFO, PubMed, Scopus	2008–2016	17	Australia, Canada, Hong Kong, Indonesia, Japan, Jordan, Philippines, Saudi-Arabia, Sweden, Taiwan, USA, multinational study in Bangladesh, Bhutan, Cambodia, Laos, Nepal, Solomon Islands
Lam et al. 201830)	To explore the core components that constitute nurses’ preparedness in an epidemic event	Nurses	Epidemic events	Peer, managerial, and institutional support, and training	BNI, CINAHL, Embase, MEDLINE	2005–2013	7	China, Hong Kong, Singapore, Taiwan, USA
Lee et al. 202132)	To identify the perceived barriers and facilitators of nurses’ and physicians’ willingness to work during a respiratory disease outbreak	Nurses and physicians	Respiratory disease outbreak (SARS, H1N1, MERS, COVID-19)	Training, supply of PPE, provision of useful information	CINAHL, PsycINFO, PubMed, Web of Science	2003–2021	29	Australia, Bangladesh, Canada, China, Georgia, Hong Kong, Nigeria, Pakistan, Philippines, Qatar, South Korea, Taiwan, Turkey, Yemen, USA
Ma et al. 202129)	To identify and synthesize the available qualitative evidence about experiences in the preparation, the deployment, and the reintegration of military nurses	Military nurses	Deployment to war or non-war military operations	Mental, physical, and professional preparation, teamwork and bonding, personal and professional development	CINAHL, Cochrane Library, EMBASE, PsycINFO, PubMed	1996–2019	16	Australia, Korea, Sweden, UK, USA
Ottisova et al. 202239)	To summarize the interventions for preventing or reducing adverse mental health outcomes, appraise the effectiveness of the interventions on psychological outcomes, and provide clinical recommendations	Health care workers	Disasters	Psychosocial interventions (single and multiple session (s), stepped-care interventions, comprehensive interventions)	AMED, BNI, CINAHL, CENTRAL, Embase, HMIC, PubMed/ MEDLINE, PsycINFO	1997–2021	14	China, France, Hawaii, Israel, Sierra Leone, Philippines, Taiwan, Turkey, USA
Poon et al. 20222)	To examine the factors affecting turnover intention among health care workers during the COVID-19 pandemic	Health care workers	COVID-19 pandemic	Organizational support (e.g., communication, leadership), working conditions	CINAHL, Embase, PubMed, PsycINFO, Scopus, Web of Science	2020–2022	43	Australia, Canada, China, Egypt, Germany, Indonesia, Iran, Italy, Lebanon, Oman, Pakistan, Peru, Philippines, Qatar, Saudi-Arabia, Turkey, United Arab Emirates, UK, USA
Rodriguez-Arrastia et al. 202235)	To synthesize and describe the emotional and psychological implications for health care professionals who provided care in a mass casualty incident or disaster	Health care workers and emergency service providers	All types of disasters (e.g., terrorist attack, explosion, mass panic)	Training and leadership	CINAHL, Nursing Allied Health Database, PubMed, PsycINFO, Scopus	1985–2020	19	Belgium, Iran, Italy, Japan, Netherlands, New Zealand, Philippines, Syria, UK, USA
Schoultz et al. 202240)	To synthesize studies on the usefulness of psychological first aid for the well-being of nursing and residential care home staff	Nursing and residential care home staff	Planned setting was crises (e.g., COVID-19 pandemic)	Psychological first aid	British Medical Journal Best Practice, Campbell Library, CINAHL, Clinical Trials, Cochrane Library, Dynamed, Ebsco, Kings Fund Library, NICE, Ovid, Proquest, Prospero, Scopus, SIGN, Social Care Online, Web of Knowledge	-	0	NA
Sirois and Owens 202128)	To examine the factors associated with psychological distress among health care workers during an infectious disease outbreak	Health care workers	Infectious disease outbreak (COVID-19, SARS, MERS, H1N1, H7N9, and Ebola)	Social, organizational, and informational support	Google Scholar, MEDLINE, PsycINFO, Web of Science	2004–2021	139	Asia Pacific Region, Argentina, Australia, Brazil, Canada, China, Egypt, Ethiopia, France, Greece, Hong Kong, India, Iran, Israel, Italy, Japan, Jordan, Kurdistan, Libya, Malaysia, Mali, Oman, Pakistan, Palestine, Russia, Saudi-Arabia, Serbia, Sierra Leone, Singapore, South Korea, Spain, Taiwan, Turkey, UK, USA, one multinational study
Temeng et al. 202431)	To explore the experiences and coping strategies of nurses caring for patients during severe viral disease pandemics	Nurses	Severe viral pandemics (SARS, MERS, H1N1, COVID-19)	Organizational factors) when caring patients with severe viral disease	ASSIA, CINAHL, MEDLINE, PsycINFO, Scopus	2005–2021	71	Brazil, Canada, China, Ecuador, Hong Kong, Indonesia, Iran, Italy, Japan, Jordan, Lebanon, New Zealand, Philippines, Saudi Arabia, South Korea, Spain, Taiwan, Turkey, USA
Tolksdorf et al. 202236)	To identify factors associated with nurses’ turnover intention during the COVID-19 pandemic	Nurses	COVID-19 pandemic	Employer support (transformational leadership, organizational culture) and work demands (deployment, working hours, job strain, job security)	CINAHL, MEDLINE, PsycArticles, PsycINFO, PSYNDEX, SocINDEX	2020–2021	19	Australia, Canada, Egypt, Indonesia, Iran, Lebanon, Pakistan, Philippines, Qatar, Romania, Taiwan, Turkey, UK, USA
Winders et al. 202141)	To explore the effectiveness of interventions provided to first responders to prevent and/or treat the mental health effects of responding to a disaster	First responders (rescue personnel, firefighters)	Natural disasters, pandemics, mass accidents, and human conflicts	Critical incident stress debriefing, CBT and other forms of psychotherapy, psychoeducation + fish oil	MEDLINE, PsycINFO, Scopus	1992–2018	25	Armenia, Australia, China, Finland, Iran, Israel, Japan, Lebanon. Netherlands, Philippines, Taiwan, UK, USA

AMED: Allied and Complementary Medicine Database; ASSIA: Applied Social Sciences Index and Abstracts; BNI: British Nursing Index; CBT: Cognitive Behavioral Therapy; CENTRAL: Cochrane Central Register of Controlled Trials; CINAHL: Cumulative Index to Nursing and Allied Health Literature; HMIC: The Health Management Information Consortium; NA: not available; NICE: National Institute for Health and Care Excellence; PPE: personal protective equipment; RCT: randomized controlled trial; SIGN: Scottish Intercollegiate Guidelines Network.

Table 3. Characteristics of the included systematic reviews: critical appraisal and analysis.

First author’s name, publication year and reference	Appraisal instruments used	Appraisal rating	Method of analysis	Relevant outcome (s) assessed	Relevant findings	Significance/direction	Comments
Baetzner et al. 202237)	JBI critical appraisal tool	Not reported	Narrative synthesis	Knowledge and skills, job performance in simulations, self-reported measures of preparedness, readiness, or confidence	All training methods were at least partially effective in preparing medical first responders for disasters, but technology-based interventions led to similar or greater outcomes.	Technology-based interventions are suitable for preparing and training medical first responders to disasters. Virtual/mixed reality training methods might offer a more immersive and realistic training experience, but more research into the effectiveness of these training methods is needed.	Studies published in English were included.
Boone et al. 202334)	JHEPB	At least two reviewers	Thematic synthesis	Mental health and well-being	Key factors associated with nurses’ well-being and safety during crises were supportive leadership and emergency preparedness planning. Interventions that were effective in supporting nurses’ mental health included wellness programs in which self-care and stress management were prioritized, students were paired with practicing nurses to serve as wellness partners, and informational and psychological support was provided at the organizational level.	Nurses’ mental health can be supported with emergency preparedness and planning and by having access to both individual and system interventions that support mental well-being. Additional research into potentially effective support measures is needed to ensure nurses´ well-being and support during future public health crises.	Studies published in English were included.
Curtin et al. 202233)	CASP qualitative checklist	Two reviewers and one judge	Thematic synthesis	Resilience, mental health, well-being, adaptability, psychological endurance, emotional adjustment, and emotional stability	Well-being and resilience of health care workers were supported by working environments where health care workers’ viewpoints were considered and where they were involved in decision making processes, leadership, supportive management, and proficient training as well as collegial support.	To support health care workers’ resilience during pandemics, it is important that organization prioritizes employees’ well-being (e.g., access to PPE) and supports peer networks, organizational leaders address health care workers’ concerns, communicate in a timely and consistent manner, and are open to feedback, and employees are included in the decision-making process.	Studies published in English were included.
De Brier et al. 202026)	GRADE	Two independent reviewers	Narrative synthesis; meta-analysis was not possible	Psychiatric symptoms, mental health symptomatology, and psychologic well-being outcomes	The provision of support programs (supportive interactions with supervisors and training supportive skills) by health care organizations putatively benefitted mental health in health care workers during coronavirus pandemics.	Embedding mental health support to promote collegial social support and personal sense of control could help to maximize resilience of health care workers. There is a need for studies reporting on the effectiveness of concrete mental health interventions and utilizing better study designs.	Studies published in English were included.
Ding et al. 202222)	Cochrane Collaboration risk of bias tool	Two independent reviewers	Narrative synthesis	Symptoms or levels of anxiety, stress, burnout, post-traumatic stress, and sleep quality	All coping methods significantly improved psychological well-being (stress or sleep quality) in health care workers during COVID-19.	Easily accessible online-based programs are recommended as intervention strategies to support health care workers’ psychological well-being during pandemics. Further studies using quantitative analysis are warranted.	Studies published in English were included.
Labrague 202127)	JBI critical appraisal tool	Two independent reviewers	Narrative synthesis	Psychological and mental health (e.g., traumatic stress, emotional distress, psychological distress, burnout, anxiety and stress)	Adequate managerial, supervisorial, and social support (support from colleagues, peers) were associated with reduced traumatic stress and anxiety and improvement in self-efficacy in nurses during the COVID-19 pandemic.	Substantial evidence supports the effectiveness of resilience and social support to preserve psychological and mental health among health care workers during COVID-19 pandemic. Investigations are needed to explore how resilience, coping behaviors, and social support among health care workers change through the pandemic.	Studies published in English were included.
Labrague et al. 201838)	Appraisal checklist for quantitative studies by Kmet et al. 2004	Not reported	Thematic synthesis; meta-analysis was not possible	Disaster preparedness	Nurses’ disaster preparedness was low to moderate. Better disaster preparedness was attributed to previous disaster response experience, disaster training, and involvement in workplace disaster planning.	Strategies recommended for enhancing disaster preparedness include offering possibilities to participate in disaster training and drills that mimic actual events, involvement in institutions’ disaster planning, and inclusion of disaster topics into nursing curriculums to raise awareness among nurses. There is a need for further research to identify factors that support disaster readiness and preparedness in nurses.	Studies published in English were included.
Lam et al. 201830)	CASP qualitative checklist	Two independent reviewers, disagreements solved through discussion	Narrative synthesis	Preparedness for infectious disease outbreaks	Better preparedness was associated with knowledge about infectious diseases (e.g., disease manifestation and protective measures), peer support, effective leadership (practical instructions, communication), and resources and equipment provision by administration.	Nurses’ preparedness for infectious disease outbreaks can be supported by education and training (e.g., interactive teaching and learning sessions) and assistance and support from hospitals (e.g., resource allocation, PPE, supportive atmosphere, reciprocity, and supportiveness in leader-co-worker relationships). Further research on the dynamic process of preparedness development is recommended.	Studies published in English were included.
Lee et al. 202132)	MMAT	Two reviewers, disagreements solved through discussion	Sequential explanatory synthesis	Willingness to work under respiratory disease outbreak	Willingness to work was associated with training for pandemics (knowledge and skills, related to pandemics and PPE training).	Education and training for nurses should be regularly implemented in preparation for an unexpected respiratory disease outbreak. Future studies are suggested to consider health system differences between countries along with the factors that influence willingness to work both in actual outbreak situation and hypothetical situation.	Studies published in English were included.
Ma et al. 202129)	JBI QARI	Two independent reviewers, disagreements solved with a third reviewer	Qualitative meta-synthesis	Job-related outcomes such as development of professionalization, commitment to duty, psychological transition process to deployment	Nurses experienced a range of psychological reactions and felt unprepared during deployment. Importance of teamwork and how individuals in a team bond with each other was emphasized.	It is difficult for military nurses to adapt the transition from civilian care to deployment environment. Nurses will be more likely to cope with the deployment via being well prepared, having support, as well as achieving professional and personal growth. Nurse managers should sustain a competent nursing team by proposing training protocols for the potential challenges during deployment cycle. Future research should explore how to maintain a competent, stable, and ready nursing team while mitigating the negative effect of deployment on nurses.	Studies published in English were included.
Ottisova et al. 202239)	Quality appraisal tool by Hawker et al. 2002	Two independent reviewers	Effect size (Cohen’s d) and Reliable Change Index	Anxiety, depression, PTSD, and burnout symptoms and compassion fatigue	Effective interventions to reduce PTSD and anxiety symptoms included individual and group-based CBT land comprehensive interventions targeted to specific skills and processes (e.g., in-service skills training, behavioral activation, mindfulness). Single-session debriefing and psychological first aid workshops have shown only limited efficacy.	There is limited evidence on psychosocial interventions for health care workers faced with disasters, with the most evidence for CBT-based approaches. Further research should include controlled evaluations of interventions and aim to target identified risk factors.	No restrictions on language.
Poon et al. 20222)	JBI critical appraisal tool and MMAT	Two independent reviewers, disagreements solved through discussion	Converted integrated approach, and thematic categorization; meta-analysis could not be performed	Turnover intentions during COVID-19 pandemic	Reduced turnover intentions were associated with resilience, job satisfaction, and social support. Increase in workload, working long hours, traumatic experiences, deployment to other departments, and poor safety climate were positively correlated with increased turnover intentions.	Multiple interpersonal, job-related, and organizational factors influence health care workers turnover intention during pandemic. Future research should focus on specific factors, such as working conditions or burnout, and specific vulnerable groups, such as migrant health care workers.	Studies published in English were included.
Rodriguez-Arrastia et al. 202235)	CASP (qualitative studies), STROBE (quantitative studies)	Two independent reviewers and one judge	Narrative synthesis	Psychological distress and disorders	Emotional and psychological implications caused by mass casualty incidents can be mitigated by social support. Training of skillsets to know how to work under pressure and uncertainty to better respond and manage disasters is important.	Organizations, head nurses and other health service managers need to foster resilience and flexibility among their employees to improve self-care during a disaster, as well as ensure policies to address a lack of emotional preparedness among their personnel. Strategies to consider first include CBT and psychoeducation. Further research is needed to understand the efficacy of these strategies, as well as prevention protocols for organizations to follow in these scenarios.	Studies published in English or Spanish were included.
Schoultz et al. 202240)	NA	Not reported	NA	Mental well-being	There was no empirical evidence of psychological first aid effective post-disaster training or interventions. However, delivering social, emotional, supportive, and pragmatic interventions have the potential to protect against PTSD.	The lack of evidence calls for studies on psychological first aid, particularly among residential care home staff.	No single study met the inclusion criteria. Inclusion criteria publication in English.
Sirois and Owens 202128)	11 questions from AXIS	Two independent reviewers and one judge	Narrative synthesis	Psychological distress	Psychological distress during an infectious disease outbreak can be reduced by receiving direct social support from colleagues and supervisors as well as organizational support, e.g., receiving adequate communication and information about the outbreak and precautionary measures from the organization.	Receiving collegial, supervisory, and organizational social support is associated with lower distress. Providing health care workers with adequate resources (e.g., PPE, training, clear guidelines, information, and protocols for infection control) is important to lower psychological distress. Further research is warranted on the content of intervention to mitigate distress.	Studies published in English were included.
Temeng et al. 202431)	JBI critical appraisal tool	Two independent reviewers, disagreements solved through discussion	Convergent integrated approach (JBI SUMARI)	Physical and social well-being	Organizational strategies to assist nurses during viral respiratory disease outbreaks included frequent communications from leaders, counselling sessions, improved working conditions, regular educational programs, and financial incentives.	Social support, improved working conditions and training can help mitigate the challenges to develop and implement effective supportive systems pre- and post-pandemics.	Studies published in English were included.
Tolksdorf et al. 202236)	SURE	Appraisal evenly divided between three reviewers, one of who checked all extracted data	Narrative synthesis; meta-analysis could not be conducted	Turnover intention	Lower levels of turnover intention were associated with supportive leadership, employer or social support, and good organizational culture. Higher levels of turnover intention were associated with increased working hours or workload, higher job strain and insecurity, being poorly prepared for the COVID-19 pandemic, and feeling not connected to work community, insufficient communication about plans for pandemic, and insufficient occupational safety.	Ways to reduce turnover intentions during pandemics include social support systems, positive workplace culture and having sufficient plans for future crisis situations. There is a need for more research regarding factors affecting turnover intentions in a crisis.	Studies published in English or German were included.
Winders et al. 202141)	GRADE (quantitative studies), CASP (qualitative studies)	Not reported	Descriptive analysis	Mental health outcomes, including PTSD, anxiety, and depression scales	While heterogenous in execution, psychological interventions were effective in reducing symptoms of anxiety, hyperarousal, and depression in first responders after disasters.	Psychological interventions are likely to both prevent and treat psychiatric symptoms in first responders, however, most studies focused on treatment rather than prevention. Future work needs to focus on symptom prevention and pre-event interventions.	Studies published in English, Spanish, and French were included.

The column Heterogeneity testing was left out from Table 3, as none of the systematic reviews had performed heterogeneity testing. AXIS: Appraisal Tool for Cross-Sectional Studies; CASP: Critical Appraisal Skills Programme; CBT: Cognitive Behavioral Therapy; GRADE: Grading of Recommendations, Assessment, Development, and Evaluations; JBI: the Joanna Briggs Institute; JHEPB: The Johns Hopkins Evidence-Based Practice Appraisal Tool; MMAT: Mixed Methods Appraisal Tool; NA: not applicable; PPE: personal protective equipment; PTSD: post-traumatic stress disorder; QARI: Qualitative Assessment and Review Instrument; STROBE: Strengthening the Reporting of Observational studies in Epidemiology; SURE: Specialist Unit for Review Evidence.

Organizational and social support

Three systematic reviews examined exclusively organizational and social support as WMSs^26,27,28) and nine as one of the included WMSs^{2, 29,30,31,32,33,34,35,36)}. Table 4 presents the WMSs included in these publications. The four most frequently covered WMSs were a) effective communication and provision of useful information, b) supportive leadership, c) colleague support, d) provision of adequate PPE and other supplies, and e) provision of appropriate working conditions (e.g., practical briefings, positive atmosphere, job control, working hours and workload).

Table 4. Organizational and social support related concrete workload management strategies used in the included systematic reviews.

First author’s name, publication year and reference	Effective communication, provision of useful information	Implementation of well-being programs	Implementation of training	Access to mental health services	Provision of PPE and other supplies	Adequate staffing	Provision of adequate working conditions	Provision of insurance and compensation	Supportive leadership	Colleague support
Boone et al. 202334)	X	X			X	X	X		X
Curtin et al. 202233)	X			X		X	X		X	X
De Brier et al. 202026)	X		X	X		X		X	X	X
Labrague 202127)	X		X		X		X		X	X
Lam et al. 201830)	X				X				X	X
Lee et al. 202132)	X		X	X	X
Ma et al. 202129)										X
Poon et al. 20222)	X	X					X		X
Rodriguez-Arrastia et al. 202235)									X	X
Sirois and Owens 202128)	X								X	X
Temeng et al. 202431)	X				X		X
Tolksdorf et al. 202236)	X						X		X

PPE: personal protective equipment.

The target population targeted exclusively nurses in four of the systematic reviews^{30, 31, 34, 36)} and licensed military nurses in military hospitals in one²⁹⁾, health care employees in general in five^{2, 26,27,28, 33)}, health care employees and other emergency service providers in one³⁵⁾, and nurses and physicians in one³²⁾. The external crises in the included reviews concerning organizational and social support was pandemic or epidemic in ten of these publications^{2, 26,27,28, 30,31,32,33,34, 36)}, natural or man-made disasters in one³⁵⁾, and war and non-war military operations in one²⁹⁾.

Training

Of the 18 systematic reviews only one examined exclusively training³⁷⁾ and seven training as one of the included WMSs^{31,32,33,34,35,36, 38)}. All the eight publications addressed training as a way to improve professional skills needed in external crises (e.g., infection control, triage, pre-hospital support) through classroom and online sessions, virtual reality sessions, and exercises and drills, while only one addressed training also as a way to improve stress management³⁵⁾.

The population was exclusively nurses in three of the publications^{31, 34, 36)}, exclusively military nurses in one²⁹⁾, all health care employees in two^{33, 38)}, medical first responders in general in one³⁷⁾, health care employees and emergency service providers in one³⁵⁾, and nurses and physicians in one³²⁾. The external crisis was pandemic or epidemic in six of the studies^{30,31,32,33,34, 36)}, natural or man-made disasters in three^{35, 37, 38)}, and war and non-war military operations in one²⁹⁾.

Psychological interventions

Of the 18 publications four examined exclusively psychological interventions as WMSs^{22, 39,40,41)} and two as one of the included WMSs^{33, 34)}. The interventions included in these six publications addressed those targeted at all employees at risk and those primarily aimed at employees with mental health symptoms or conditions following exposure to external crisis. The former included a) wellness programs and well-being centers^{22, 33, 34)}, b) Pre-Traumatic Vaccination (PTV)³³⁾ and c) breath based meditation. The latter included a) a partnership wellness program³⁴⁾, b) various types of single techniques (Eye Movement Desensitization and Reprocessing (EMDR), Diaphragmatic Breathing Relaxation Training (DBRT), and emotional freedom techniques (EFT))^{22, 39)}, c) packages of meditation and psychoeducation^{22, 39)}, d) short, structured interventions delivered immediately or shortly after a traumatic event (psychological debriefing, Psychological First Aid (PFA))^{33, 39,40,41)}, e) professional mental health counselling and consultation^{33, 39, 41),} and f) Cognitive Behavioral Therapy (CBT) and other forms of psychotherapies^{22, 39, 41)}.

Exclusively nurses were studied in one review³⁴⁾, health care employees in general in three reviews^{22, 33, 39)}, first responders (e.g., rescue personnel, firefighters) in one⁴¹⁾, and nursing and residential care home staff in one⁴⁰⁾. The external crises was pandemic or epidemic in three reviews^{22, 33, 34)}, and both pandemic or epidemic and natural or man-made disasters in the other three^39,40,41).

Quality appraisal

According to the JBI Critical Appraisal Instrument for Systematic Reviews tool criteria, 15 of the 18 (83%) systematic reviews were of high quality, and three of moderate quality (17%). All the systematic reviews were included in the final analysis, as they were rated to have “yes” answer to the pre-determined definite quality criteria. The quality appraisal ratings are included in Table 5.

Table 5. Quality appraisal of the included systematic reviews with the JBI Critical Appraisal Instrument for Systematic Reviews.

First author’s name, publication year and reference	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Quality level
Baetzner et al. 202237)	yes	yes	yes	yes	yes	uc	yes	yes	uc	yes	yes	high
Boone et al. 202334)	yes	yes	yes	yes	yes	uc	uc	yes	na	yes	yes	high
Curtin et al. 202233)	yes	yes	yes	yes	yes	uc	uc	yes	na	yes	no	moderate
De Brier et al. 202026)	yes	yes	yes	no	yes	uc	no	yes	no	yes	yes	moderate
Ding et al. 202222)	yes	yes	yes	no	yes	yes	yes	yes	na	yes	yes	high
Labrague 202127)	yes	yes	yes	yes	yes	yes	yes	yes	no	yes	yes	high
Labrague et al. 201838)	yes	yes	yes	yes	yes	uc	uc	yes	no	yes	yes	high
Lam et al. 201830)	yes	yes	no	yes	yes	yes	uc	yes	na	yes	yes	high
Lee et al. 202132)	yes	yes	yes	yes	yes	yes	no	yes	no	yes	yes	high
Ma et al. 202129)	yes	yes	yes	yes	yes	yes	uc	yes	na	yes	yes	high
Ottisova et al. 202239)	yes	yes	yes	yes	yes	yes	no	yes	no	yes	yes	high
Poon et al. 20222)	yes	yes	yes	yes	yes	yes	yes	yes	no	yes	yes	high
Rodriguez-Arrastia et al. 202235)	yes	yes	yes	yes	yes	yes	uc	yes	no	yes	yes	high
Schoultz et al. 202240)	yes	yes	yes	yes	na	na	na	na	na	na	yes	high
Sirois and Owens 2021	yes	yes	uc	no	yes	yes	yes	yes	no	yes	yes	high
Temeng et al. 202431)	yes	yes	yes	yes	yes	yes	no	yes	no	yes	no	high
Tolksdorf et al. 202236)	yes	yes	yes	yes	yes	uc	uc	yes	no	yes	yes	high
Winders et al. 202141)	yes	yes	uc	yes	yes	uc	uc	yes	uc	yes	yes	moderate

The JBI criteria: Q1. Is the review question clearly and explicitly stated? Q2. Were the inclusion criteria appropriate for the review question? Q3. Was the search strategy appropriate? Q4. Were the sources and resources used to search for studies adequate? Q5. Were the criteria for appraising studies appropriate? Q6. Was critical appraisal conducted by two or more reviewers independently? Q7. Were there methods to minimize errors in data extraction? Q8. Were the methods used to combine studies appropriate? Q9. Was the likelihood of publication bias assessed? Q10. Were recommendations for policy and/or practice supported by the reported data? Q11. Were the specific directives for new research appropriate? Uc: unclear, na: not applicable.

Associations of WMSs with employee well-being

Organizational and social support

All the 12 systematic reviews examining organizational and social support reported positive associations between these WMSs and employee well-being and/or negative associations in the absence or inefficiency of these WMSs^{2, 26,27,28,29,30,31,32,33,34,35,36)}. The most frequently reported outcomes for employee well-being were self-reported stress, anxiety, turnover intention, willingness to work, and self-reported mental well-being and health. Only one systematic review reported the lack of association, which was the association between access to well-being centers and turnover intention²⁾. All the reported associations were correlative (i.e., non-causal).

Training

All the eight publications examining training reported positive associations between these WMSs and employee well-being or negative associations in the absence or insufficiency of these WMSs^{31,32,33,34,35,36,37,38)}. The most frequently reported outcomes for employee well-being were self-reported preparedness to work in external crisis. The other outcomes were self-reported stress, resilience, fear, confidence, and efficacy. Most of the associations were either clearly correlative or based on quasi-experimental studies. Only one publication also included results from trials (randomized controlled trials (RCTs), non-RCTs or pre-post testing)³⁷⁾. This systematic review was limited to disaster preparedness and therefore did not include studies on the effectiveness of training during external crisis.

Psychological interventions

Five of the six systematic reviews examining psychological interventions reported positive associations between these WMSs and employee well-being^{22, 33, 34, 39, 41)}. One publication examining PFA to support care and nursing home staff reported no evidence⁴⁰⁾. The most frequently reported outcomes for the employee well-being were self-reported stress, anxiety, and depression symptoms. The other self-reported outcomes were related to Post Traumatic Stress Disorder (PTSD), burnout, sleep quality, resilience, and mental and psychological well-being in general. Most of the associations were correlative. Positive causal associations with mental well-being (based on RCTs) were reported for an online well-being program, EFT, mindfulness-based mental health intervention, CBT, and a modified version of Critical Incident Stress Debriefing (CISD)^{22, 39, 41)}. “Standard” debriefing, integrative psychotherapy, and PFA were the interventions for which no positive associations with employee well-being were reported^{39, 41)}. In addition, one publication found a reliable change (based on the Reliable Change Index) for EMDR, EFT but not for DBRT or debriefing³⁹⁾.

Discussion

This umbrella review aimed to synthesize and assess current research evidence on workload management strategies for supporting well-being of nurses, paramedics, and firefighters during external crises. The main finding was that most of the employee and work-directed strategies examined in the included systematic reviews were either positively associated with employee well-being during various kinds of external crises or negatively associated with inadequacy. Most of the associations found were correlative and based on a mix of qualitative and quantitative studies. There were no meta-analyses amongst the included systematic reviews. All the outcomes of employee well-being were self-reported and collected either through interviews or questionnaires, which can be a influenced by situational factors and retrospective recall bias⁴²⁾. Most of the outcomes assessed stress, psychological symptoms, and preparedness or willingness to work in external crisis. Overall, these results support the comprehension that employee well-being can be enhanced through both employee and work directed WMSs during external crisis.

The most frequently examined category of WMSs was organizational and social support, which included a wide range of single WMSs. The evidence mostly focused on effective communication, provision of useful information by managers, supportive leadership and colleague support, and provision of adequate working conditions. The latter can also be considered to include the provision of PPE and other supplies and adequate staffing, which were considered as separate categories in the narrative synthesis. Even though the systematic reviews on organizational and social support predominantly focused on work during pandemics, the evidence on clear communication, providing information and supportive leadership has clear relevance to other types of external crises as well. The finding of occupational and social support as potential WMS for external crisis in this umbrella review is consistent with systematic reviews showing the importance of organizational and social support as job resources in health care in general^{38, 43, 44)}.

In the included systematic reviews, training had been mainly examined as a way of increasing employees’ knowledge and improving their practical skills needed during external crisis^{27, 31,32,33,34,35,36,37)}. Training can be used to proactively develop employees’ strategies for coping with stress was rare amongst the original studies and included only in one review³⁵⁾. The training methods ranged from traditional methods, such as classroom sessions and exercises and drills, to newer digital methods, such as online and virtual reality sessions. Based on the included systematic reviews, it is not possible to prioritize any of these methods, but the evidence from studies looking at training as a way of promoting occupational health and safety suggests that methods with a strong element of engagement, such as gamified and immersive digital methods, are effective in changing behavior into desired direction^45,46,47,48).

The psychological interventions addressed in the included systematic reviews focused on either all employees at risk or on those with current mental health symptoms or conditions related to external crises, both of which showed potential as an effective WMS. This finding is in line with the finding that access to mental health services as such is positively associated with employee well-being during external crises^{26, 32, 33)}. The association of EFT, a mindfulness-based mental health intervention, and CBT with employee well-being in the context of an external crisis were each shown in a RCT³⁹⁾, which means that the association can be considered causal, while the other associations were correlative. Another important observation is that an improvement in mental health following a psychological intervention may be statistically significant but not reliable (i.e., clinically meaningful)³⁹⁾. This observation suggests that more than one psychological intervention method or WMS is needed to achieve a practically meaningful difference to employee well-being in external crises. This notion is consistent with studies on the effectiveness of mental health interventions^{49, 50)} and workplace health promotion interventions not focusing on external crises^51,52,53).

Although most of the positive associations of different WMSs with employee well-being in the context of external crisis were correlative and not necessarily practically meaningful, there are some points of view that support their use in the workplaces. First, the included systematic reviews assessed employee well-being across a wide range of outcome measures, countries, and external crises, suggesting that the benefits of these WMSs are fairly consistent and generalizable. Second and as mentioned above, it is advisable to apply multiple WMSs simultaneously, which is likely to significantly increase the overall effectiveness of the workplace’s attempt to support employee well-being during external crisis. Third, the way in which an intervention is developed and implemented in the workplace is crucial to its effectiveness^54,55,56). Implementation facilitators include, for example, the involvement of both management and employees in the process. Proactive approach is an important aspect of the development and implementation process in the present context. Most of the WMSs covered in this review, such as supportive leadership, provision of adequate working conditions, and practical skills training, are difficult to apply in the middle of an external crisis unless they are developed and implemented in advance.

As an implication for future research, there is a need for more research and especially research synthesis on WMSs among paramedics and firefighters during external crises. As the included reviews predominantly reported results on mental health and different types of training as strategies to improve employees’ well-being, resilience and/or reduce workload during external crisis, there is a need for systematic reviews on focusing WMSs on physical workload, as well as on recommendable shift scheduling and break arrangements in all the occupations included in this umbrella review.

There are obvious strengths of this review, such as focusing a timely and globally relevant topic of effectiveness of WMSs among occupational groups that are working in frontline during external crises, covering a wide range of well-being outcome measures, countries, and types of external crisis. Keeping up with the growing number of research on the lessons learned from previous external crisis, especially the COVID-19 pandemic, requires this kind of research synthesis and practical implications to the workplaces.

There are also some limitations to consider. The associations found between the WMSs, and employee well-being were mostly correlative, which means that the actual benefits of the addressed WMSs remain uncertain. This umbrella review only included systematic reviews published in English, which in turn, had mostly included original studies published in English^{2, 26, 27, 29,30,31,32,33,34, 37, 38, 40)} or in a few major West-European languages^{35, 36, 41)}. Both language restrictions may have missed relevant studies. Additionally, the heterogeneity of the included publications in terms of the type of studies they reviewed (e.g., quantitative vs. qualitative) and predominance of cross-sectional study settings in the original studies complicates assessing the overall benefits of the WMSs.

Conclusions

To support well-being of nurses and first responders during external crises, both employee-directed and work-directed workload management strategies are applicable. Within the employee-directed strategies, proactive practical skills training and the provision of psychological interventions are most promising. Within the work-directed strategies, effective communication, providing useful information, adequate working conditions, supportive leadership, and peer support seem to be important factors. How these workload management strategies are developed and implemented in the workplace is crucial to their success.

Practical Implications

Based on the available research evidence, the authors recommend that the workplaces of nurses, paramedics, and firefighters, in collaboration with occupational health services, develop or update a detailed plan for managing the workload of their employees during external crisis, and consider both employee and work-directed strategies and interventions in such a plan. Within the employee-directed strategies, proactive practical skills training, and the provision of psychological interventions for both those at risk and those with current mental health symptoms have the best potential to support employee well-being. Within the work-directed strategies, effective communication and provision of useful information, provision of adequate working conditions, supportive leadership, and peer support appear to be among the most important factors. When developing and implementing these strategies and interventions, it is important to consider research evidence on the factors that make the intervention successful, such as involving management and employees in the process.

Author Contributions

Study conception and design: KK, JH, SM, AP, MSi, PS, MSa. Data collection: KK, SP, MSi, MSa. Data analysis and interpretation: KK, JH, SM, AP, MSi, PS, MSa. Writing the original draft: KK, MSa. Critical revision of the manuscript: KK, JH, SM, AP, SP, MSi, PS, MSa. Accepting the final version: KK, JH, SM, AP, SP, MSi, PS, MSa.

Funding

This study was funded by the Finnish Work Environment Fund (grant no 220413) and the Finnish Institute of Occupational Health.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Availability of Data and Materials

The first authors confirm that all the data generated or analyzed during the study are available from the first authors upon reasonable request.