Worker experiences of the work health and safety impacts of exposure to dying and death in non-clinical settings: a qualitative scoping review

Figures & data

Figure 1. PRISMA-ScR flow diagram of the scoping review process for article selection.

Table 1. Article ID, study reference and demographic information of the participants of included Studies/Articles.

Article ID, Study reference (Author, Year, Country)	Work context	Occupation and role	Number of participants and gender N= (M/F)
1. Abelsson (2019) Sweden	Emergency Services	Firefighters as first responders in the community	34 (M) 1 (F)
2. Barbee et al. (2016) USA	Emergency Services	First Responder, Emergency Medical Technician (EMT), and EMT-Paramedic levels attending pediatric deaths	76 (M) 22 (F)
3. Colombo et al. (2019) Italy	Cemetery	Technician employees, technicians and specialists of decoration and garden, gravediggers, administrative and front office employees	21 (M) 73 (F)
4. Flynn et al. (2015) USA	Mortuary	Military and civilian mortuary workers	28 (M) 6 (F)
5. Fullerton et al. (1992) USA	Emergency Services	Firefighters in mass disaster relief	Not provided, 8 focus groups. All male
6. Keller et al. (2002) USA	Disaster Relief	Physicians - oncology, psychiatry, surgery, and internal medicine and nurses	10 (gender not provided)
7. Halpern et al. (2009) Canada	Emergency Services	Supervisors and front-line ambulance workers	40 (M) 20 (F)
8. Lakeman (2011) Ireland	Homeless Service	Homeless sector worker - majority non-professionally affiliated, social work and psychiatry	16 (gender not provided)
9. Levkovich and Duvshan (2020) Israel	Education	Homeroom high school teachers	7 (M) 9 (F)
10. McCarroll et al. (1993) Canada and USA	Disaster Relief	Airforce personnel, forensic pathologists, fire fighters, police officers, emergency medical technician, military officers, non-commissioned officers, psychiatrist, funeral director.	490 (M) 210 (F)
11. Mitchell and Munro (1996) Scotland	Emergency Services	Probationary police constables	145 (M) 67 (F)
12. Nelson et al. (2020) England	Emergency Services	Paramedics, one advanced technician and one station manager attending suicides	6 (M) 3 (F)
13. Regehr et al. (2002) Canada	Emergency Services	Paramedics, including supervisors	86 (gender not provided)
14. Robson and Williams (2017) Australia	Allied Health	Podiatrists	4 (M) 11 (F)
15. Fernández-Aedo et al. (2017) Spain	Emergency Services	Emergency medical technicians and emergency nurses working basic life support or advanced life support units in the emergency ambulance transport network	7 (M) 9 (F)

Figure 2. Flowchart of themes.

Table

Search ID#	Search Terms	Notes	Results
1	exp work*	Searched as Medical Subject Headings (MeSH)	4258
2	exp occupation*	Searched as keywords	48450
3	S1* OR S2*	Combining sets for concept 1
4	exp death OR dead	Searched as keywords	249926
5	die		25095
6	“Attitude to death”	Searched as MeSH	5224
7	S4 AND S5 OR S6	Combining sets for concept 2	11666
8	exp coping OR cope	Searched as keywords	77574
9	Impact*	Searched as keywords	447137
10	S8 OR S9	Combining sets for concept 3	513004
11	S3 AND S7 AND S10		1051

Table

Inclusion Criteria

Exclusion Criteria

Articles that: Were focused on patient death and dying in non-clinical settings (i.e. community) Were published between 1971 and 2021 Included participants exposed to death in their paid or volunteer worker role Were written in English language Were published in peer reviewed journals Reported Qualitative or mixed methods research results Were focused on dying and dead (humans)

Articles that focus on: Concept of dying/death rather than workers’ experience of dying Patient focused clinical settings (i.e. hospital, residential care homes) Bereaved families Patient/victim/family rather than workers’ experiences Impacts other than death-related impacts or where death-related impacts were minor focus of study Students rather than workers Personal rather than work-related exposure to dying/death Intervention/training rather than impacts of exposure to dying/death Assessment/instrument development Soldiers/Veterans Covid-19 related research

Table

Theme	Illustrative quotes	Sub themes and article ID
1. Environment	‘We perform CPR because we believe that relatives want us to. More so to show those watching that we are doing something. Otherwise, they think “Why aren’t they doing something?”’ [1] ‘Healthcare professionals don’t know what we do; GPs [primary care doctors] haven’t a bloody clue what we do’ [12] ‘We’re the service what everyone uses and abuses’ [8]	Cultural Expectations: Heroism [1, 2, 7, 15] Stigma [3, 4, 12] Physical environment: [4–6, 10,12] Economic Environment: [8, 12]
2. Workplace	‘I do not like working with personal effects … When I’m working with personal effects, I’m knee deep in somebody’s life. There’s no way of keeping it at arm’s distance anymore’.’ [4] ‘It makes you think, well, maybe I shouldn’t be doing this. It sort of undermines your confidence in the job or your ability to do the job’ [7] ‘Here everyone in their sectors is overloaded with work, the areas are many, and being few [of us] unfortunately we are forced to overload ourselves with work’ [3]. ‘You have to have a safe place to do it and I don’t think internally is a safe place regardless of how brilliant the organisation is, it is not safe’ [8]	Organisational expectations: Sense of duty [1, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 15] Unclear professional boundaries [1, 6, 9, 10, 11, 12, 13] Resources: Lacking support, time or training [1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14]
3. Job demands	‘Because we’re now being asked to do the police’s job, and the police are taking 40 min to get to a job: it’s a potential crime scene. You learned very, very quickly, to stick up for yourself, whether it was clinically, personally, professionally … because paramedics are the lowest common denominator’ [12] ‘We simply perceive this as a place of work’ [6] ‘I saw the families who live in mourning, who live tragic situations and I was sick’ [6] It was horrific; it was like a horror movie! [The deceased] basically, the body had exploded the belly and everything [12]	Prolonged or mass exposure: [3, 4, 5,6, 10, 13] Sensory exposure [4, 5, 6, 8, 10, 13] Age of the dead [1, 2, 3, 5, 7, 8, 9, 15, 11, 12, 13] Interacting with families [1–5, 7, 8, 11, 12, 13, 14] Identifying with the dead [4, 5, 6, 8, 10, 12, 13]
4. Impacts	‘I keep it together at work but fall apart at home’ [9] ‘ … grotesque, burned or mutilated bodies; emotional involvement with the dead; smells of decomposing or burnt corpses; and tactile stimuli experienced during the manipulation or transport of body parts’ [6] ‘Managing emotion aspects is tiring’ [3] ‘I couldn’t sleep. I just constantly … it was like a horror movie, I just kept seeing this [person]’ [12] ‘I’d go to bed, I’d close my eyes, and there would be the lady doing a swan dive off the balcony again, as clear as you sitting in front of me’; [13]	Emotions and memories: [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] Grief [4, 5, 7, 8, 9, 12, 13, 14, 15] Guilt: [5, 7, 8, 9, 12, 13, 15] Stress: [1, 4, 5, 6, 7, 9, 11, 12, 13, 15] Sensory experience: [4, 5, 6, 7, 8, 10, 12, 13] Stress and trauma: [2, 4, 7, 9, 12, 13] Burnout [2, 3, 9, 12, 13] Physical and behavioural reactions: [5, 6, 7, 8, 9, 10, 12, 13] Alcohol [2, 7, 10, 13]
5. Coping	‘We tend to be heartless in what we do and people say “Well didn’t that affect you?” It probably affects us all, it’s just that we’ve developed sort of a nice thick skin to a lot of the calls, as a protective mechanism’ [13] ‘We did what we always did – talked it out among ourselves and our trusted peers to learn and to decompress … Discussed what we could have maybe done differently and cried’ [2] ‘Because you’re busy doing stuff and your mind is focusing on what you have to do’ [7] ‘For me, it’s writing it down. Nobody reads it. It’s just a good way to vent it off for me’ [7] ‘Focusing intently so as to not allow horror to enter’ [6]	Psychological defence mechanisms: Compartmentalisation/detachment [1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] Focusing on the job and doing everything they can [1, 6, 7, 8, 10, 11, 13, 15] Collegial support: [1, 2, 4, 5, 7, 8, 10, 13, 15] Humour [5,6, 7, 10, 11] Attending funerals (8, 9, 14] Individual strategies: Meaning of work [4, 6, 7, 8, 15] Accepting lack of control (8, 15] Professional support (8, 13] Family support (8, 10, 12, 13]

Table

Section	Item	Prisma-ScR Checklist Item	Reported on page #
TITLE
Title	1	Identify the report as a scoping review.	Page 1
ABSTRACT
Structured summary	2	Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.	Page 1
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.	Page 2–4
Objectives	4	Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g. population or participants, concepts, and context) or other relevant key elements used to conceptualise the review questions and/or objectives.	Page 2–4 aim and purpose and research question
METHODS
Protocol and registration	5	Indicate whether a review protocol exists; state if and where it can be accessed (e.g. a Web address); and if available, provide registration information, including the registration number.	No protocol registered
Eligibility criteria	6	Specify characteristics of the sources of evidence used as eligibility criteria (e.g. years considered, language, and publication status), and provide a rationale.	Page 4–6 Search Strategy and Appendix B inclusion and exclusion criteria
Information sources*	7	Describe all information sources in the search (e.g. databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.	Page 5
Search	8	Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.	Appendix A - Supplemental material
Selection of sources of evidence†	9	State the process for selecting sources of evidence (i.e. screening and eligibility) included in the scoping review.	Page 5–6
Data charting process‡	10	Describe the methods of charting data from the included sources of evidence (e.g. calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.	Page 6–7
Data items	11	List and define all variables for which data were sought and any assumptions and simplifications made.	See summary in Tables 1, Appendix B and Appendix C.
Critical appraisal of individual sources of evidence§	12	If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).	Not undertaken as part of a scoping review, addressed on page 22
Synthesis of results	13	Describe the methods of handling and summarising the data that were charted.	Pages 6–7
RESULTS
Selection of sources of evidence	14	Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.	Page 7, Figure 1
Characteristics of sources of evidence	15	For each source of evidence, present characteristics for which data were charted and provide the citations.	Page 7–8, Table 1
Critical appraisal within sources of evidence	16	If done, present data on critical appraisal of included sources of evidence (see item 12).	Not undertaken as part of a scoping review, addressed on page 22
Results of individual sources of evidence	17	For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.	Page 8, Figure 2 and Appendix C
Synthesis of results	18	Summarize and/or present the charting results as they relate to the review questions and objectives.	Page 8–19
DISCUSSION
Summary of evidence	19	Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.	Page 19–22
Limitations	20	Discuss the limitations of the scoping review process.	Page 22
Conclusions	21	Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.	Page 23
FUNDING
Funding	22	Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.	No funding available

JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

*Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.

†A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g. quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).

‡The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.

§The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of ‘risk of bias’ (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g. quantitative and/or qualitative research, expert opinion, and policy document).

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