Table A1.

Data Synthesis.

	Coxon et al. (2017) [18]								GRADE
Methods for data collection and analysis	Qualitative methodology based on semi-structured interviews. Data analysis followed a grounded-theory approach, or bottom-up thematic, using an inductive framework for analysis.								HIGH
Phenomena of interest	The focus of this study was set on the unique experiences of emergency medical service (EMS) dispatch personnel, which may produce specific stressors.
Setting/Context/Culture	The study was carried out in England, UK using emergency dispatch staff.
Participant characteristics/sample size	Nine participants from the Emergency Operations Centre (EOC) were recruited via purposive sampling to reflect variety in years of experience, age, and gender. As the total population of EOC dispatch workers was 36, the number of participants recruited represented a quarter of this workforce.
Description of main results	Theme 1: How dispatch is perceived by others		Theme 2: Sources of stress				Theme 3: Dispatch stress reducers
	Participants felt overlooked, misunderstood and marginalised. Friends and family minimalized the importance of their professional roles. Team relationships with field EFRs were also impeded by a poor perception of dispatch roles. This led to intrapersonal conflicts and completing tasks ouside the scope of the dispatch’s role.		Participants felt a sense of purpose in their job, that they have made a difference for people in need. Lack of resources was nonetheless noted—dispatch staff was often confronted with a lack of ambulances for emergency, which increases the response time. Intrapersonal issues impaired interaction with other EFRs. Need to constantly multitask and coordinate. Lack of training. Cumulative fatigue from one day to the next.				Good training is a coping mechanism. Induces feelings of value and appreciation for the team while improving job satisfaction. Personal motivation. Seeing the difference made to people.
Implications for practice	Poor intra-personal relationships between dispatch staff in emergency services and filed operatives contributes significantly to job stress. Inadvertently, this may lead dispatch staff to feel undervalued and underappreciated, decreasing job satisfaction and leading to substantial turnover rates. These data indicate that organisations that run dispatch EFR services should be mindful of developing good intrapersonal relations between their dispatch staff and other EFR teams.
	Dropkin et al. (2015) [19]								GRADE
Methods for data collection and analysis	Qualitative methodology with semi-structured interviews and focus-groups. Grounded theory thematic analysis approach. A preliminary pilot interview to guide the development for the interviews and focus-groups questions was carried.								HIGH
Phenomena of interest	Study explores work-related health problems for emergency medical service (EMS) workers, to identify potential risk factors at the organisational level, task-related risks, exposure risks and potential preventive strategies.
Setting/Context/Culture	Study carried out in the US, in the context of role development and expansion of job attributes for EMS.
Participant characteristics/sample size	EMS and supervisors recruited from the largest hospital-based ambulance service in North-East US. Ten teams were interviewed Focus-groups were carried out with 68 supervisors and 22 EMSs. Most participants were over the age of 35 years old, white, and all were men. 85% of them had back problems, and 55% rated their health as good or excellent. Musculoskeletal problems were reported by all participants.
Description of main results	Theme 1: Most common physical health problems	Theme 2: Risk factors						Theme 3: Challenges for tackling these risks
	Back pain and shoulder injuries. Other fitness issues reported. Impact on staffing and job rotation, as well as medical care.	Supervisors and EMS alike identified the work organisation as a risk factor due to work characteristics, patient characteristics and partner pair-up. These risk factors impacted training, equipment, shift hours and sometimes required having a second job.						Trust and social support at work was low. Rest and meal breaks were sparse or substandard. Financial issues. Training shortage. Additional issues reported were financial issues, hourly shifts, equipment availablility, and lack of job rewards and respect.
Implications for practice	Risks to physical wellbeing seem to derive from work specificities for EFRs. The way in which organisations can mitigate these risks is by screening employees for fitness before hire, providing adequate training and equipment. To mitigate psychosocial risks, organisations could enable partnerships in shift working between people who can work together well, schedule shifts to allow sufficient rest days, and allow for rest breaks and meals.
Eriksen (2019) [20]									GRADE
Methods for data collection and analysis	Qualitative methodology based on semi-structured interviews and focus groups, and analysed via the thematic coding software NVivo.								HIGH
Phenomena of interest	The experiences of emergency workers in coping, caring and believing during disaster recovery. Investigation is centred around three concepts: faith as performativity, embodiment and the holding environment, as components of a system that regulates coping capacity. Faith in this context does not reflect religious belief, but rather inter-group relations in crisis situations.
Setting/Context/Culture	Disaster recovery workers from Australia. Participants had work experience in New South Wales or Victoria, and were faith leaders, group supervisors, recovery coordinators, volunteers and community care workers
Participant characteristics/sample size	18 people working in disaster recovery for the interviews, plus another sample of 33 participants for focus-groups.
Description of main results	Theme 1: Risk management of formative tensions			Theme 2: Embodying work and modalities of faith
	Self-care and coping strategies	Points of exposure to harm		Spiritual Response				Psychological and physiological response
	Having a sense of prioritising and experiential knowledge. Training, debriefing, safe-space and ability to ask for help. Leadership and group communication. Adaptability under pressure. Disasters elicit a sense of community.	Prolonged exposure to risks and organisational pressures. Conflicting views. Limited listening from leaders and co-workers. Control-based power dynamics. Negative sensory experiences. Trigger points. Isolation. Personal impacts. A small group of participants mentioned media and news reading as sources of harm, due to dramatic approach of disaster coverage.		Feeling a sense of connectedness coming from a love for humanity. Religious beliefs. Religion as a way to cope with stress. Innate resilience, and spirituality.				In the context of disasters, the feelings of connectedness and spirituality seemed to promote actions of providing support to others but also feelings of being overwhelmed, overloaded and fragile. Inadequacies in the intervention, limited resources as well as frustrations were also reported. For some participants, disaster work also produced changes in their weight, increases in adrenalin and burnout.
Implications for practice	The holding environment, described as the cultural and physical space in which the disaster occurs, seems to influence the ability of disaster recovery workers to cope with the effects of being exposed to these events. Disasters seem to naturally cause a greater sense of community among people and by this, elicit interventional responses, albeit with some psychological and physiological costs to the disaster worker. Organisations can therefore foster this sense of community, spirituality and social support to increase coping skills in their work force. Study recommends a coping model based around individual grounded faith and faith that is collectively created.
Paterson et al. (2014) [21]									GRADE
Methods for data collection and analysis	Mixed-methods approach following a survey design combined with three additional open-ended questions. Quantitative data was analysed via descriptive means. Qualitative data analysed via systematic coding and theme extraction.								HIGH
Phenomena of interest	How fatigue is perceived by paramedics and what factors are thought to contribute to fatigue.
Setting/Context/Culture	Study was carried out in Australia, using a sample of paramedics.
Participant characteristics/sample size	49 paramedics were included in the study. 20 worked in ambulance services for 5 to 10 years. 12 worked in the ambulance service for 10 to 15 years. 7 participants had been employed in the service for less than 5 years. 7 had been employed for more than 20 years.
Description of main results	Theme 1: Working Time	Theme 2: Sleep		Theme 3: Workload		Theme 4: Health and Wellbeing		Theme 5: Work–life Environment
	Night shifts are the main cause of fatigue. Associated with performance impairments in the absence of breaks.	Difficulty sleeping outside night shifts, particularly before the night shift. Imbalanced circadian rhythm. Poor home environment. Sleep interruptions.		Increased work load was also reported as a contributor to fatigue, yet this was more pronounced doing night shifts where activity seemed to be more intense.		Exhaustion and mood swings exacerbated by poor diets and limited exercise time leading to weight gain.		Living in a rural area associated with being fatigued due to commute. Increased heath waves and bushfire incidents contribute to fatigue. Poor work–life balance: participants had to work their way around family responsibility, work and learning.
Implications for practice	By acknowledging fatigue factors among their staff, organisations can develop interventional models to mitigate or eliminate these factors. The implementation of such as system would potentially be complex, as initially organisational research would have to be conducted to identify sources of fatigue, and interventions developed based on the attained results.
Pyper and Paterson (2016) [22]									GRADE
Methods for data collection and analysis	Mixed-methods approach to assess levels of fatigue, stress and emotional trauma in rural and regional ambulance personnel. Fatigue was assessed via the Chalder’s Fatigue Questionnaire (CFQ). Depression was assessed by using the Depression Anxiety Stress Scale (DASS-21), and emotional trauma was assessed via the Impact of Event Scale (IES). Data analysed via descriptive statistics as well as qualitative coding of open-end questions.								HIGH
Phenomena of interest	The study sought to determine if similar levels of fatigue and stress are present within rural and regional ambulance staff.
Setting/Context/Culture	The investigation was carried out in Australia.
Participant characteristics/sample size	The sample consisted of 134 ambulance workers from regional and rural areas.
Description of main results	Theme 1: Fatigue				Theme 2: Stressors
	High levels of fatigue and emotional trauma reported by ambulance staff working in rural and regional areas, despite serving a lower population when compared to urban ambulance staff.				Unique stressors include having to provide emergency medical services to people that are personally known by ambulance staff. However, personal involvement may also increase professionalism and care.
Implications for practice	Organisations managing emergency first responses in rural and regional areas should be aware of the fact that workload is not the only factor affecting fatigue, stress and emotional trauma in their staff.