Secondary traumatization in first responders: a systematic review

Figures & data

Table A1. Reviewed studies: characteristics and statistical design

Study	Participants (N)	Questionnaire	Descriptive statistics	Group comparisons	Correlations	Regressions	Limitations reported by authors and further limitations
Amjad and Rafique (2013)	N = 60 rescue workers	ProQOL	x		x	x	Generalizability, only workers with 10 or more years of formal education; measures developed for western society, some items may be culturally biased (assessment in India) Further limitations: sample size, cross-sectional design
Argentero and Setti (2011)	N = 782 rescue workers	STSS	x		x	x	Generalizability due to social and cultural context (assessment in Italy); previous experience of personal trauma not considered, cross-sectional design
Battle (2011) Dissertation	N = 1390 police officers	ProQOL	x	x			Trauma defined as self-perceived trauma, measured via self-report (yes–no items); no representative sample (single-centre assessment)
Bissett (2002) Dissertation	N = 240 firefightersand paramedics	CFST	x	x	x		Homogeneity of responses and lack of symptom reporting (potential social desirability bias due to group data collection); possible history effect due to tropical storm (more symptoms reported shortly after the disaster); cross-sectional design; generalizability
Bourke and Craun (2014)	N = 965 ICAC investigators	STSS	x	x		x	Unclear response rate; cross-sectional design; previous personal trauma not assessed; generalizability
Burruss et al. (2017)	N = 360 ICAC police officers	STSS				x	Study participants: trainees; prior work experience not assessed; only quantitative measures employed Further limitation: cross-sectional design
Chiappo-West (2017)	N = 153 police officers	ProQOL	x		x		ProQOL had no published validity statistics at time of submission; organizational environment unknown; no cause determined; self-report measures: not generalizable to the law enforcement profession
Crampton (2014) Dissertation	N = 87 paramedics	ProQOL	x	x			Stigma associated with PTSD may hinder participants’ responses; generalizability; cross-sectional design; several questionnaires rejected due to positive bias scores; low sample size
Craun and Bourke (2015)	N = 350 ICAC taskforce members	STSS			x		Cross-sectional design; generalizability
Döllinger (2014) Dissertation	N = 110 rescue services and paramedics	STSS	x			x	Items on sexual traumatic experiences excluded due to violation of privacy concerns; no information on non-responders; participants: short length of service; social bias; not representative participants; generalizability Further limitation: cross-sectional design
Hargrave (2010) Dissertation	N = 165 police officers + N = 148 volunteer crisis workers	Secondary Trauma Scale	x	x	x	x	Retrospective recall; possible confounding variables; only police officers and crisis workers who had attended sudden death were assessed; cross-sectional design
Howell (2016) Dissertation	N = 73 dual-skilled firefighters/paramedics	ProQOL	x		x		Short period of time to collect data: sample size, individuals on sick leave not included; limited demographic information due to participants’ anonymity; generalizability
Krieger III (2017) Dissertation	N = 228 CAC law enforcement investigators and forensic interviewers	STSS			x		Non-random sample; positive response bias
Krutolewitsch and Horn (2017)*	N = 168 rescue service and firefighters	STQ	x			x	Self-report measures developed for western society, some items may be culturally biased (assessment in Russia); cross-sectional design
Krutolewitsch et al. (2015)*	N = 168 rescue service and firefighters	STQ	x	x	x		Cross-sectional design; no Russian norm sample available
Krutolewitsch et al. (2016)*	N = 168 rescue service and firefighters	STQ	x		x	x	Self-report measures developed for western society, some items may be culturally biased (assessment in Russia); cross-sectional design
LaFauci Schutt and Marotta (2011)	N = 269 emergency management professionals	ProQOL	x			x	Non-random, fairly homogeneous volunteer sample; Internet survey (return rate unknown, possible differences between responders and non-responders); self-report measures; potential social desirability bias Further limitation: cross-sectional design
Lane et al. (2009)	N = 47 detectives investigating sexual child abuse and assault cases	ProQOL			x		Only two participants scored above cut-off score on PCL (positive response bias); data gathered at a conference; personal sexual abuse history not assessed; sample size
Pietrantoni and Prati (2008)	N = 961 first responders	ProQOL	x		x	x	Cross-sectional design; no qualitative methods
Prati and Pietrantoni (2010a)	N = 586 rescue workers	ProQOL	x	x	x	x	Retrospective self-reports of critical incident exposure (recall bias); cross-sectional design
Prati et al. (2010)	N = 451 rescue workers	ProQOL	x		x	x	Self-report measures; only one single item to assess stress appraisal; cross-sectional design
Prati et al. (2011)	N = 463 emergency workers	ProQOL	x		x	x	Self-report measures; only one single item to assess stress appraisal; cross-sectional design; lack of information on larger population and sampling method
Reinhard and Maercker (2004)	N = 92 rescue service workers	STQ	x		x	x	Questionnaires: possibly blurred validity; return rate c. 29% (no information on non-responders) Further limitation: cross-sectional design
Robinson (2017) Dissertation	N = 129 full-time firefighters	ProQOL			x	x	Return rate 49.8%; population size experiencing CF; generalizability Further limitation: cross-sectional design
Scott (2016) Dissertation	N = 21 parole officers	STSS		x			Sample size; clustering participants into groups based on specific offer types; contact not possible; self-report measure; potential social desirability bias
Setti and Argentero (2012)	N = 724 ambulance operators	STSS	x	x			Generalizability, only internal validity reported
Setti and Argentero (2014)	N = 176 firefighters	STSS	x		x	x	Cross-sectional design; lack of symptoms (other protective factors not considered); self-report measures; population not fully representative
Setti et al. (2016)	N = 782 rescuers, e.g. ambulance, first aid operators, military, firefighters, police officers	STSS	x	x	x	x	Cross-sectional design; no missing data procedure; self-report measures; sample heterogeneous
Tehrani (2016)	N = 126 police officers; Internet child abuse investigators	ProQOL	x	x	x	x	Low levels of traumatic stress symptoms reported Further limitation: cross-sectional design
Tracy (2012) Dissertation	N = 40 emergency medical technicians	CS/CFST	x		x	x	75% of participants were assistant emergency medical technicians (lowest ranking staff); single-centre assessment; exposure to trauma low; self-report measures Further limitations: sample size; cross-sectional design, generalizability
Turgoose et al. (2017)	N = 142 police officers	ProQOL	x	x	x		Cross-sectional design; validity; many participants may have had little contact with victims

CF, compassion fatigue; CFST, Compassion Fatigue Self-Test; CS, compassion satisfaction; CS/CFST, Compassion Satisfaction/Compassion Fatigue Self-Test; (I)CAC, (Internet) Crime Against Children; PCL, PTSD Checklist; ProQOL, Professional Quality of Life Scale; PTSD, post-traumatic stress disorder; STQ, Secondary Trauma Questionnaire; STSS, Secondary Traumatic Stress Scale.

* Same set of data.

Table A2. Reviewed studies: descriptive statistics and reported references range

Study and participants (N)	Reported reference range	Descriptive statistics
ProQOL
Amjad and Rafique (2013) N = 60 rescue workers	CF: M = 13, SD = 6.3	CF: M = 28.56, SD = 4.63
Battle (2011) Dissertation N = 1390 police officers	CF: M = 13, SD = 6.3	CF: M = 13.75, SD = 7.45 (officers who had experienced perceived trauma); M = 10.69, SD = 5.99 (officers who had not experienced perceived trauma)
Chiappo-West (2017) N = 153 police officers	t-Scores: M = 50; cut-off 57	STS: M = 49.8, SD = 9.5
Crampton (2014) Dissertation N = 87 paramedics	No reference range	CF: evaluated via self-report: 43% of urban paramedics, 23% of rural paramedics; questionnaire: 46% of urban paramedics, 32% of rural paramedics STS: urban: 34% average, 66% high; rural paramedics: 32% average, 68% high
Howell (2016) Dissertation N = 73 dual-skilled firefighter/paramedics	< 22: low score 23–41: average score > 42: high score	CF: M = 38.44, SD = 5.86 (average bordering on high levels) STS: M = 20.63, SD = 5.14 (average bordering on low levels)
LaFauci Schutt and Marotta (2011) N = 269 emergency management professionals	> 17: at risk of CF	CF: means comparable to manual’s reported levels; > 17: 14.7% indicating risk of CF; > 43: 13.2% indicating PTSD diagnosis in non-clinical population
Pietrantoni and Prati (2008) N = 961 first responders	Revised Italian version No reference range	CF: M = 2.04, SD = .58
Prati and Pietrantoni (2010a) N = 586 rescue workers	Revised Italian version No reference range	CF: M = 1.85, SD = .58 (medical workers: M = 1.76, SD = .57; firefighters: M = 1.95, SD = .59)
Prati et al. (2010) N = 451 rescue workers	Revised Italian version No reference range	CF: M = 1.74, SD = .26
Prati et al. (2011) N = 463 emergency workers	Revised Italian version scale Midpoint: 2.50	CF: M = 1.74, SD = .57
Robinson (2017) N = 129 career firefighters	t-Scores, cut-off: ≥ 56 for burnout or STS	F: > 55: n = 45 at high risk of developing CF; < 56: n = 84 not at high risk of developing CF
Tehrani (2016) N = 126 police officers; Internet child abuse investigators	CF: cut-off 1: 10; cut-off 2: 15	CF: M = 9.7, SD = 6.0 (female); M = 6.1, SD = 5.2 (male) STS: 4% of males and 7% of females reported clinical levels
Turgoose et al. (2017) N = 142 police officers	CF: subscales were categorized as low, average, and high STSS: reference to Bride (2007); little/no STS (scores < 50th percentile), mild, moderate, high, and severe STS	CF: M = 18.4, SD = 4.7; 84% scores ranked as being low, 16% being average, and none as high STS: M = 32.5, SD = 10.6 (work experience ≥ 1 year M = 37.0, SD = 11.7, n = 67; work experience < 1 year M = 29.8, SD = 9.0, n = 40; working with adults: M = 34.3, SD = 10.7, n = 72; working with children: M = 27.4, SD = 8.5, n = 34); 74% no or mild level, 11% moderate, 8% high, and 8% severe; low levels of intrusion and avoidance, mild levels of arousal
STSS
Argentero and Setti (2011) N = 782 rescue workers	No reference range	VT: intrusion: M = 2.02, SD = .80; avoidance: M = 2.07, SD = .81; arousal: M = 1.93, SD = .72
Bourke and Craun (2014) N = 965 ICAC investigators	Reference to Bride (2007); categorization into no/little, mild, moderate, high, and severe levels of STS	STS: M = 2.11 indicating that symptoms occur ‘rarely’
Döllinger (2014) Dissertation N = 110 rescue service and paramedics	No reference range	STS: M = 15.92, SD = 3.62, range 10–30; 95.5% low strain, 4.5% average strain
Setti and Argentero (2012) N = 724 ambulance operators	Italian version, no reference range	Intrusion: M = 2.02, SD = .78 (females: M = 2.14, SD = .74; males: M = 1.98, SD = .77); avoidance: M = 1.93, SD = .69; arousal: M = 2.07, SD = .80 (younger participants: M = 2.20, SD = .87, older: M = 1.94, SD = .70)
Setti and Argentero (2014) N = 176 firefighters	High scores: post-traumatic symptoms	Intrusion: M = 1.67, SD = .54; arousal: M = 1.85, SD = .51
Setti et al. (2016) N = 782 rescuers	No reference range	Intrusion: M = 2.02, SD = .80; 63.1% of respondents reported at least one intrusion symptom; avoidance: M = 1.93, SD = .72; 27.5% affirmed three items on the avoidance subscale; hyperarousal: M = 2.07, SD = .81; 39.8% affirmed at least two items on the hyperarousal subscale
CFST
Bissett (2002) Dissertation N = 240 firefighter paramedics	< 27: extremely low risk 27–30: low risk 31–35: moderate risk 36–40: high risk > 40: extremely high risk	CF: M = 32.65, SD = 9.07, range: 23–82; 25.4% extremely low risk (n = 60), 25.8% low risk (n = 61), 24.2% moderate risk (n = 57), 9.8% high risk (n = 23), 14.8% extremely high risk (n = 35)
STQ
Krutolewitsch and Horn (2017)* N = 168 rescue service and firefighters	Cut-off: 38	ST: 13.1% clinical level
Krutolewitsch et al. (2015)* N = 168 rescue services and firefighters	No reference range	ST: 13.1% clinical level, 7.7% mild level, 5.4% severe level; (rescue services: 7.6% mild and average level, 13.2% severe level; firefighters: 6.7% mild and average level, 1.7% severe level)
Krutolewitsch et al. (2016)* N = 168 rescue services and firefighters	Cut-off: 38	ST: M = 29.95, SD = 7.96; 13.1% clinical level: 7.7% mild level, 5.4% severe level
Reinhard and Maercker (2004) N = 92 rescue service workers	No reference range	STQ attendant symptoms: M = 10.93, SD = 4.26, range 1–30 Study-validated questionnaire
Secondary Trauma Scale
Hargrave (2010) Dissertation N = 165 police officers N = 148 volunteer crisis workers	Cut-off: 38 moderate response; > 44 severe response	STS: M = 21.57, SD = 5.07, range 18–42 (police M = 21.92, SD = 5.37; volunteers M = 21.17, SD = 4.70); 3.5% scored in mild to severe range
CS/CFST
Tracy (2012) Dissertation N = 40 emergency medical technicians	Reference to Conrad and Kellar-Guenther (2006)	CF: > 60% at extremely low risk, M = 25.18, SD = 14.08

CF, compassion fatigue; CFST, Compassion Fatigue Self-Test; CS, compassion satisfaction; CS/CFST, Compassion Satisfaction/Compassion Fatigue Self-Test; ICAC, Internet Crime Against Children; ProQOL, Professional Quality of Life Scale; PTSD, post-traumatic stress disorder; ST, secondary traumatization; STQ, Secondary Trauma Questionnaire; STS, secondary traumatic stress; STSS, Secondary Traumatic Stress Scale; VT, vicarious traumatization.

* Same set of data.

Conrad, D., & Kellar-Guenther, Y. (2006). Compassion fatigue, burnout, and compassion satisfaction among Colorado child protection workers. Child Abuse & Neglect, 30(10), 1071–1080.

Table A3. Reviewed studies: group comparisons

Study and participants (N)	Questionnaire	Group 1	Group 2	Statistics
ProQOL
Battle (2011) Dissertation N = 1390 police officers	ProQOL	Officers perceived trauma (M = 13.75, SD = 7.45)	Officers not perceived trauma (M = 10.69, SD = 5.99)	CF: F(1,1389) = 53.00, p < .0005, partial η^2 = .040
Crampton (2014) Dissertation N = 87 paramedics	ProQOL	Rural paramedics	Urban paramedics	CF: no significant difference
Prati and Pietrantoni (2010a) N = 586 rescue workers	ProQOL	Firefighters (M = 1.95, SD = .59)	Emergency and medical service personnel (M = 1.79, SD = .57)	CF: t(566) = −3.185, p = .002, d = .28
Tehrani (2016) N = 126 police officers; Internet child abuse investigators	ProQOL	Females (M = 9.70, SD = 6.00)	Males (M = 6.1, SD = 5.2)	CF: t-test, p = .007
Turgoose et al. (2017) N = 142 police officers	ProQOL	Police officers who had served in this function for ≥ 1 year (M = 37.0, SD = 11.7, N = 67) Police officers working with adults (M = 34.3, SD = 10.7, N = 72)	Those in function for < 1 year (M = 29.8, SD = 9.0, N = 40) Police officers working with children (M = 27.4, SD = 8.5, N = 34)	STS: t(104) = 3.6, p = .001; t(104) = 3.3, p = .001
STSS
Bourke and Craun (2014) N = 965 ICAC investigators	STSS	Personnel in UK (M = 1.99) UK sample: more respondents in low/no category (USA: 26.4%; UK: 36.9%)	Personnel in USA (M = 2.16) US sample: more respondents in severe category (USA: 15.3%; UK: 10.4%)	STS: t(944) = 3.40, p < .001; χ^2(4, n = 941) = 13.15, p = .01
Scott (2016) Dissertation N = 21 parole officers	STSS	Singular ethnic group	Multi-ethnic group	STS: multi-ethnic group showed higher resilience (χ^2 = 11.422, p = .001)
Setti and Argentero (2012) N = 724 ambulance operators	STSS	Females (M = 2.14, SD = .74) Younger participants (M = 2.20, SD = .87)	Males (M = 1.98, SD = .77) Older participants (M = 1.94, SD = .70)	Intrusive thoughts: (F = 6.14, p < .05) arousal: (F = 4.19, p < .01)
Setti et al. (2016) N = 782 rescuers	STSS	Professionals (EE: M = 2.06, SD = 1.38; DP: M = 1.97, SD = 1.42; avoidance M = 2.08, SD = .79; hyperarousal M = 2.19, SD = .89)	Volunteers (EE: M = 1.58, SD = 1.24; DP: M = 1.44, SD = 1.27; avoidance M = 1.86, SD = .67; hyperarousal M = 2.01, SD = .77)	EE: F(1) = 24.27, p < .01; DP: F(1) = 26.84, p < .01; avoidance F(1) = 15.77, p < .01; hyperarousal F(1) = 8.05, p < .05
CFST
Bissett (2002) Dissertation N = 240 firefighter paramedics	CFST	Paramedics on duty (M = 33.27, SD = 9.35, n = 147) during disaster response efforts in the wake of storm Allison	Paramedics not on duty (M = 31.69, SD = 8.61, n = 87)	CF: no significant difference
STQ
Krutolewitsch et al. (2015) N = 168 rescue service and firefighters	STQ	Rescue service (M = 32.75, SD = 9.75) Females	Firefighters (M = 28.08, SD = 6.52) Males	ST: t = −3.18, p = .002; risk 6× higher (odds ratio), χ^2 = 15.73, df = 1, p = .000; ST: females at higher risk than males, odds ratio 4:2
Secondary Trauma Scale
Hargrave (2010) Dissertation N = 165 police officers; N = 148 volunteer crisis workers	Secondary Trauma Scale	Police officers (M = 21.92, SD = 5.37)	Volunteer crisis workers (M = 21.17, SD = 4.70)	STS: no significant differences (t = 1.30)

CF, compassion fatigue; CFST, Compassion Fatigue Self-Test; DP, depersonalization; EE, emotional exhaustion; ProQOL, Professional Quality of Life; ST, Secondary Traumatization; STQ, Secondary Trauma Questionnaire; STS, secondary traumatic stress; STSS, Secondary Traumatic Stress Scale.

Table A4. Reviewed studies: correlation and regression analyses

Study and participants N)	Questionnaire	Correlation and regression analyses
Amjad and Rafique (2013) N = 60 rescue workers	ProQOL	Correlations: CF corr. with work life quality (r = −.85, p < .01), CS (r = −.39, p < .01), B (r = .76, p < .01)
Argentero and Setti (2011) N = 782 rescue workers	STSS	Correlations: VT corr. with social support: intrusion r = −.23, avoidance r = −.31, arousal r = −.26 (all p < .01); predictability of job support: intrusion r = −.09, avoidance r = −.16, arousal = −.18 (all p < .01; job support: avoidance r = −.20 (p < .01) Regressions: three regression models: individual and organizational factors influence intrusion (R^2 = .083), avoidance (R^2 = .133), arousal (R^2 = .089); role clarity has most sig. influence on intrusion (β = −.251), avoidance (β = −.301), arousal (β = −.231, all p < .01)
Bissett (2002) Dissertation N = 240 firefighters and paramedics	CFST	Correlations: CF corr. with PTSD severity (r = .76, p < .05), B (EE: r = .50, p < .05; DP: r = .42, p < .05; PA: r = −.08, p > .05) Factor analysis: result supported three-factor model of PTSD severity (avoidance/distractibility, restlessness/irritability, and anxiety/intrusion), factors were not a strict representation of the three symptom clusters assessed for PTSD diagnosis Regressions: B predicts CF (R^2 = .27, F(4,214) = 20.05, p < .01) with EE = primary predictor (β = .52, p < .01), other three burnout factors (DP, job skills, PA) not sig., EE score was entered into the regression model alone (β = .53, p < .01; R^2 = .28)
Bourke and Craun (2014) N = 965 ICAC investigators	STSS	Regressions: In UK personnel, predictors of STS explained 44% of variance [F(11,219) = 17.69, p < .001] and 52% of variance in US personnel [F(16,593) = 37.85, p < .001]; similarities, e.g. coping through denial (UK β = .21, p < .001; USA β = .13, p < .001), increase in tobacco use (UK β = .19, p < .01; USA β = .12, p < .001), increase in alcohol use (UK β = .17, p < .01; USA β = .12, p < .001); differences, e.g. more frequent use of coping through social support (USA β = −.10, p < .005), gender (USA β = −.06, p = .05) only in US sample
Burruss et al. (2017) N = 360 ICAC police officers	STSS	Regressions: exposure to CAC (β = .221, p < .001) predicted ST (R^2 = .074); female gender (β = .191, p < .001) and trauma (β = .393, p < .001) predicted coping behaviour (R^2 = .212)
Chiappo-West (2017) N = 153 police officers	ProQOL	Correlations: STS corr. with work engagement (r = −.254, p = .000) Regressions: CS (β = .749, p < .01), B (β = −.010, p = .912), STS (β = −.076, p = .273) explained 59.7% of variance of work engagement [F(2,149) = 76.07, p < .001]
Craun and Bourke (2015) N = 350 ICAC taskforce members	STSS	Regressions: frequency that humour is used at victim’s expense (β = .18, p < .001), joking about society/human behaviour (β = .11, p = .02); frequency (β = .21, p < .001) and difficulty with child exploitation material (β = .18, p < .001), increase in alcohol use (β = .20, p < .001), coping through denial (β = .15, p = .01) predict STS [R^2 = .46; F(16,310) = 20.48, p < .001]; non-predictors: utilizing humour at expense of offenders (p = .97); more frequent use of humour with sexual innuendo (p = .10)
Döllinger (2014) Dissertation N = 110 rescue services and paramedics	STSS	Regressions: STS is not a mediator between trauma exposition and post-traumatic stress (no sig. relationship between trauma exposure and PTSD [B = −.04, t(108) = −.68, p = .497]
Hargrave (2010) Dissertation N = 165 police officers + N = 148 volunteer crisis workers	Secondary Trauma Scale	Correlations: STS related to younger age of deceased (r = −.15), lower trauma resolution (r = −.18, p < .01), lower peri-event needs (r = −.17); emotional (r = .28, p < .01), cognitive (r = .36, p < .01), and total identification (r = .38); distress at survivor reactions (r = .45, p < .01), peritraumatic distress (r = .53, p < .01), current distress (r = .58, p < .01), finding it helpful talking to family/friends as support strategy (r = .16, p < .01), unrelated to specific traumatic experience Regressions: peri-event reaction (peritraumatic distress β = .21, and distress at survivor reactions β = .21) explained 11% of variance in STS, 1% pre-event and 1% post-event after controlling for current distress and group which explained 34% [R^2 = .47, F(12,249) = 18.56, p < .01]
Howell (2016) Dissertation N = 73 dual-skilled firefighters/paramedics	ProQOL	Correlations: neuroticism corr. with STS [r(70) = .409, p < .01]; no sig. corr. between extraversion and STS; no sig. corr. between psychoticism and CS, B, STS; no sig. corr. between age or length of service and CF, B, STS
Krieger III (2017) Dissertation N = 228 CAC law enforcement investigators and forensic interviewers	STSS	Correlations: having unintended thoughts about victim corr. with alcohol use (Kendall’s τ = −.119, p = .038); non-sig. corr. between time in position and emotional numbness; non-sig. corr. between having children and emotional numbness
Krutolewitsch and Horn (2017) N = 168 rescue services and firefighters	STQ	Mediation analysis: partly mediating role of disclosure and co-rumination between STS and post-traumatic growth (indirect effect of secondary PTSD via co-rumination on post-traumatic growth, Sobel Z­test: z = 2,89, p = 0,003; indirect effect of secondary PTSD via disclosure on post-traumatic growth (z = 5,94, p < .0001)
Krutolewitsch et al. (2015) N = 168 rescue services and firefighters	STQ	Correlations: traumatic work situation (injury or death of colleague) corr. with STS (r = .19, p < .05); perceives appreciation corr. with ST (r = −.24, p < .01); no sig. corr. between alcohol consumption and ST
Krutolewitsch et al. (2016) N = 168 rescue services and firefighters	STQ	Regressions: socio-interpersonal factors explain 50.4% of ST variance: demographics explain 9%, perceived appreciation 18%, disclosure 22%, co-rumination 2% (R^2 = .50; p < .05); predictors: work experience (β = −.25, p < .05), familial lack of understanding (β = .15, p < .05), secretiveness (β = .17, p < .05), emotional reaction (β = .46, p < .001), co-rumination (β = .18, p < .05)
LaFauci Schutt and Marotta (2011) N = 269 emergency management professionals	ProQOL	Regressions: personality, frequency of trauma exposure, repeated exposure symptomology explained 41% of PTSD symptoms variance [R^2 = .42, F(2,191) = 16.39, p < .0]; predictors: neuroticism (β = .38, p < .001), burnout (β = .42, p < .001), compassion satisfaction (β = .21, p < .001); predictor variables do not moderate relationship between trauma exposure frequency and PTSD symptoms; exploratory model: ethnic identity is an individual predictor in context of full model
Lane et al. (2009) N = 47 detectives investigating sexual child abuse and assault cases	ProQOL	Correlations: CF and CS not corr. with quality time, emotional intimacy, or ability to communicate openly with loved ones; PTSD symptoms corr. with B (r = .44, p < .01) and fatigue scores (r = .59, p < .01); females: emotional intimacy had no relation with B, CF, CS; no relation between open communication and B or CF
Pietrantoni and Prati (2008) N = 961 first responders	ProQOL	Correlations: CF corr. with age (r = .10, p < .01), self-efficacy (r = .11, p < .01), B (r = .57, p < .001) Regressions: sense of community (ns), collective efficacy (ns), and self-efficacy (β = −.10, p < .01) predict CF (ΔR^2 = .01, p < .05) after controlling for gender (β = .18, p < .001) and age (β = .12, p < .001, R^2 = .04, p < .001)
Prati and Pietrantoni (2010a) N = 586 rescue workers	ProQOL	Correlations: CF strongly corr. with B Path analysis: social support is resilience factor in aftermath of exposure to critical incidents; influence of receiving actual social support in a time of crisis on quality of life is mediated by perceived social support
Prati et al. (2010) N = 451 rescue workers	ProQOL	Correlations: CF corr. with length of service (r = .13, p < .01), stress appraisal (r = .34, p < .001), self-efficacy (r = −.24, p < .001) Regressions: length of service (β = .17, p < .001), stress appraisal (β = .29, p < .001), self-efficacy (β = −.23, p < .001) predict CF (R^2 = .22, p < .05); stress appraisal had sig. effect on CF, B, CS, self-efficacy may have a buffering effect
Prati et al. (2011) N = 463 emergency workers	ProQOL	Correlations: CF corr. with B (r = .64, p < .001), denial (r = .26, p < .001), self-blame (r = .27, p < .001), self-distraction (r = .29, p < .001), religion coping (r = .16, p < .001), cognitive restructuring (r = .11, p < .05), problem-focused coping (r = .14, p < .01), emotion- and support-focused coping (r = .24, p < .001), collective efficacy (r = −.10, p < .05), stress appraisal (r = .33, p < .001) Mediation analysis: partial mediation model: relation between stress appraisal and CF partially mediated by emotion- and support-focused coping, self-blame and self-distraction
Reinhard and Maercker (2004) N = 92 rescue service workers	STQ	Correlations: attendant symptoms of STS corr. with PTSD: intrusion (r = .30), avoidance (r = .44), hyperarousal (r = .43, all p < .01), trauma dose (r = .22, p < .01), EE (r = .47, p < .01), DP (r = .42 p < .01), consternation (r = .36 p < .01), perceived social support (r = −.29, p < .01); no corr. with personal fulfilment; exceptionally straining: death and injury of children, often combined with feelings of helplessness and horror Regressions: B symptoms and social support predict STQ attendant symptoms (R^2 = .28, F = 6.32, p < .001), predictors: emotional exhaustion (β = .27, p < .001)
Robinson (2017) Dissertation N = 129 full-time firefighters	ProQOL	Regressions: personality type (neuroticism) predicts likelihood of developing a high risk of CF (R^2 = 28.5%); EMS licence level and years of service were not sig. predictors for CF development
Setti and Argentero (2014) N = 176 firefighters	STSS	Correlations: mindfulness corr. with arousal (r = −.61, p < .01) and intrusion (r = −.45, p < .01); vigour (r = −.29, p < .01) and dedication (r = −.25, p < .01) corr. with arousal Regressions: mindfulness has inverse influence on arousal (β = −.59, p < .01) and intrusion (β = −.40, p = .01); seniority influences arousal (β = .40, p = .01) and intrusion (β = .38, p < .05); predictors explained 40% of arousal variance (R^2 = .42, p = .01) and 18% of intrusion variance (R^2 = .21, p < .01)
Setti et al. (2016) N = 782 rescuers	STSS	Correlations: affective commitment corr. with intrusion (r = −.081, p < .05), hyperarousal (r = −.183, p < .01), avoidance (r = −.277, p < .01); avoidance and hyperarousal not corr. with familial support; collegial support corr. with intrusion (r = −.077, p < .05), hyperarousal (r = −.139, p < .01), avoidance (r = −.196, p < .01) Regressions: social support and affective commitment explained 1.3% of intrusion variance (R^2 = .02, p < .01), predictors: collegial support (β = −.094, p < .05), familial support (β = .089, p < .05); social support and affective commitment explained 10.3% of avoidance variance (R^2 = .109, p < .01), predictors: affective commitment (β = −.239, p < .01), collegial support (β = −.116, p < .01), working position (β = −.095, p < .01); social support and affective commitment explained 4.8% of arousal variance (R^2 = .054, p < .01), predictors: affective commitment (β = −.157, p < .01)
Tehrani (2016) N = 126 police officers; Internet child abuse investigators	ProQOL	Correlations: neuroticism positive corr. with anxiety (p < .001), depression (p < .001), PTSD (p < .001), B (p < .001), and STS (p < .001) Regressions: extraversion, neuroticism, and gender explained 20% of variance for anxiety, 30% for depression, 28% for PTSD, 20% for B, 22% for STS; neuroticism predicted anxiety (β = .42; p < .001), depression (β = .46; p < .001), PTSD (β = .40; p < .001), B (β = .35; p < .001), and STS (β = .40; p < .001); female gender predicted depression (β = −.15; p < .04), PTSD (β = −.25; p < .01), and STS (β = −.19; p < .05)
Tracy (2012) Dissertation N = 40 emergency medical technicians	CS/CFST	Correlations: CF corr. with B risk (R^2 = .682, p < .01); not corr. with CS Regressions: facial expression and caregiver characteristics did not predict CF [F(9,39) = 1.249, p = .304], predictor: rank (β = .371, p < .05); personality measures and caregiver characteristics did not predict CF [F(8,39) = 1.886, p = .098], predictors: rank (β = .462, p < .05) and neuroticism (β = .432, p < .05)
Turgoose et al. (2017) N = 142 police officers	ProQOL	Correlations: CF, STS, B corr. with each other (r = .56–.66, all p < .001), but not strongly enough to warrant combining them into a single index; years working in training team of child exploitation and abuse corr. with CF (Spearman: r = .26, p < .01), STS (r = .40, p < .001) and B scores (r = .39, p < .001), results not replicated when comparing variables with years of overall experience; no corr. between CF or STS and empathy; no sig. relationships between CF, STS, B, and demographic variables of age, gender, and ethnicity

B, burnout; CS, compassion satisfaction; CF, compassion fatigue; corr., correlation, correlated; CS/CFST, Compassion Satisfaction/Compassion Fatigue Self-Test; DP, depersonalization; EE, emotional exhaustion; EMS, emergency medical services; (I)CAC, (Internet) Crime Against Children; ns, not significant; PA, personal accomplishment; ProQOL, Professional Quality of Life; PTSD, post-traumatic stress disorder; sig., significant; ST, secondary trauma(tization); STQ, Secondary Trauma Questionnaire; STS, secondary traumatic stress; STSS, Secondary Traumatic Stress Scale.

Figure A1. Flow diagram of study selection.

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