A systematic review of lifestyle and health among patrolling police officers

Abstract

Background

The police profession is a high-strain and high-risk profession, sometimes resulting in poor physical, mental and social health. This systematic review aims to identify and describe crucial areas for a healthy and sustainable lifestyle among patrolling police officers in Europe, an area not previously studied.

Methods

The review was conducted according to the PRISMA guidelines. A protocol was published and registered with PROSPERO beforehand. Searches were carried out in eight databases. Two independent authors screened articles and critically appraised the included studies. A narrative synthesis was conducted to analyse the results. The review’s total body of evidence was assessed with GRADE-CERQaul.

Results

A total of 16 articles were located, representing 13 studies. Barriers and resources for a healthy and sustainable lifestyle were linked to a theoretical framework of life balance. Subsequently, a linkage model was created to explain different aspects of patrolling police officers’ life balance and its relation to health (physical, social and mental).

Conclusions

Several crucial areas for a healthy and sustainable lifestyle were found and described, indicating that patrolling officers’ working life affects their possibilities of living a balanced lifestyle, which might disturb different aspects of health, depending on which aspect is compromised.

Keywords:

• Active duty officer
• competence
• identity
• life balance
• Model of Human Occupation
• occupational science
• relationship
• safety
• time
• work-private life

Introduction

This study intended to identify and describe crucial areas for a healthy and sustainable lifestyle for patrolling police officers in Europe. Identifying these areas will provide insight into barriers and resources for the lifestyle and health of patrolling officers. We define a patrolling officer as a uniformed police officer engaged in patrol duty. The patrolling officer is in daily communication with the public, as well as patrolling certain areas on foot or in a vehicle, keeping the public safe and upholding the law [1,2].

The police profession is globally considered a high-strain and high-risk profession, affecting police officers’ lifestyle [3], as well as physical [4,5], mental [6] and social health [7,8]. Additionally, environmental characteristics at work, such as leadership [9], work culture [10], staffing levels [11] and work schedules [12] have been found to affect police officers’ health. In turn, police work may also affect officers’ private life, including marital relationships and families [8,13], as well as influence the intersection between work and private life [14,15].

Patrolling police officers’ activities at work include maintaining order in a variety of hazardous and emotionally charged contexts and environments causing stress [16], as well as a compromised conscience for police officers [17] (for a definition of stress of conscience see, e.g. Alkrisat and Alatrash [18]). Similarly, depersonalization [19], emotional exhaustion [20] and diminished personal accomplishment [21] may occur when working as a police officer (see elements of burnout according to Maslach et al. [22]). Following traumatic events, these mental health symptoms have also been shown to cause post-traumatic stress disorder (PTSD) [23].

Likewise, high-risk contexts influence patrolling officers’ health, such as policing hotspots in high-crime areas [13] (for a definition of hotspot policing see, e.g. Sherman et al. [24]). Making moral choices and decisions fast in these contexts, while sometimes using legitimate violence is challenging. Thus, patrolling officers need to make good judgement calls [25], having congruent self-legitimacy (the power-holders’ perception of confidence in the individual power, see e.g. White et al. for definition [26]).

Also, when performing problematic arrests, factors, such as education and training are of importance [27]. Although police officers’ use of force is multifaceted; it is considered easier to make sound decisions in challenging environments when having good physical and mental health [25]. Nevertheless, the risk of being a target for violent victimization in these high-risk contexts is always present; see e.g. Muratore for a definition of violent victimization [28]. And, violent victimization may result in injury [16] and absence from work [29].

A sustainable and healthy lifestyle according to occupational science

According to the Ottawa Charter for Health Promotion (OCHP) [30] there is a link between individuals and their environments, and health is seen as a resource for everyday life. The definition of health within OCHP is based on the World Health Organization (WHO), where health is regarded as complete physical, mental and social well-being and as something more than just the absence of disease or infirmity. To reach this state of complete well-being, people must be able to identify and realize aspirations to satisfy needs, as well as to change or cope with their environments. Additionally, the OCHP emphasizes the importance of a changing pattern of life over time, including work and leisure, as well as how these patterns affect people’s health [30]. Similarly, Twinley [31] regarded a healthy and sustainable lifestyle within a person’s pattern of life to be more than just reducing risk factors for disease (drinking, smoking and physical inactivity) [31]. Thus, for a person to have a healthy and sustainable lifestyle, they also need balance in life [32].

Life balance includes a unique pattern of meaningful and satisfying occupations, incorporating all occupations in life which meet and balance basic human needs. Consequently, what persons do represent their lifestyle by matching their desired and actual time spent in valued occupations or not. Consequently, a person’s lifestyle can be experienced as balanced or imbalanced, depending on whether their needs are met or not [33,34]. Balance in life is often experienced at the same time as health, well-being and quality of life [32,34].

Preceding reviews have mainly investigated police officers’ physical and mental health [16,23,35]. Therefore, this study will complement earlier reviews by investigating patrolling police officers’ lifestyle, using a model of life balance within occupational science. This is a novel approach to apply to police health research, intending to identify crucial areas, which would aid in the understanding of what constitutes a healthy and sustainable lifestyle for patrolling officers. Hence, our more specific research questions were: What are the patrolling police officers’ barriers and resources for living a balanced lifestyle, and how does it affect their health?

Methods

The systematic review was initiated on 5 May 2020, using an initial search to refine the search strategy. The review was conducted based on a protocol according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines [36]. The protocol was registered with PROSPERO, registration number CRD42020190583 [37], and also submitted to a journal prior to data extraction [38]. Amendments to the protocol have been reported in this review, which follows the PRISMA statement [39].

Search strategy

The Population, phenomena of Interest, Context (PICo) search strategy according to Aromataris and Munn [40] was used to formulate the search string, see example shortened example of free text search string using PICo in Table 1.

Table 1. Table on the left includes the search strategy, as well as the identification and selection of relevant studies.

Search strategy, identifying and selecting relevant studies.		Coding examples from the thematic analysis and examples of concept constructs inspired by Reciprocal Translational Analysis (RTA).
Databases and other sources for including studies (search details)	Study selection criteria regarding population and context	Thematic analysis			RTA
		Coded segment in articles [Article identifier]	Category and code	Theme from LBM dimension	RTA Theme	Sub-theme and next level sub-theme
EBSCO databases (All fields): Academic Search Premiere APA PsychINFO CINAHL SOCIndex OpenGrey (All fields) Pubmed (MeSH terms were used  for the ‘Interest’ term in the PICo search strategy and a search was conducted in ‘All fields’, not just ‘Titles, Abstracts and Keywords’) Scopus (‘Title-Abs-Key’ was searched) Web of science (A ‘Topic search’  was conducted) Personal library (Six articles  from our personal library that did not show up in any of the searches).	Inclusion criteria: Patrolling police officers from EU countries were included, with no limitation regarding age or gender. Studies conducted in the Nordic countries (Iceland and Norway), and the United Kingdom. Exclusion criteria: Studies involving other groups of police officers than the targeted population. Studies focussing on specialized units of patrolling officers, or other occupational groups. Studies focussing on patrolling officers who were not on active duty. Patrolling officers and higher-ranking active-duty officers were excluded if the study did not confirm that the higher-ranking officers were also engaged in patrolling services.	The verbal use of force was observed in 24 situations; in a minority of these observations, the verbal use of force was from police officers directed towards civilians. As expected, a relationship was found between burnout and the verbal use of force. Compared to the total group of officers, those who used verbal force scored significantly higher on all three burnout scales [41]	Category: Job-related factors affecting health Code: Dangerous situations and the use of force	Biological health and physical safety	Biological health and physical safety	Sub-theme: Demanding situations, use of force and physical safety Next level sub-theme: Contributions to the use of force
Shortened example of free text search string using PICo for the EBSCO databases.		Support from the immediate supervisor, group cohesiveness, personal accomplishment and self-esteem were significantly positively related to organizational commitment [42]	Category: Rewarding and self-affirming relationships Code: The social factor affecting health	Rewarding and self-affirming relationships	Rewarding and self-affirming relationships	Sub-theme: Social support and professionality
Population – Patrolling police officers e.g. patrol OR active duty) AND (e.g. police officer OR cop) phenomena of Interest – Life contexts (environments, contexts and environmental characteristics; components and qualities from MOHO [43] interacting with a person, influencing lifestyle and health. (e.g. spaces and objects; components and qualities from the physical environment, such as police car, gun, hazards OR relationships and interactions; components and qualities from the social environment, such as communication, family, debriefing OR occupations, activities, overarching contexts; components and qualities from the occupational environment, such as time, flexibility and culture) Context – EU countries as well as Norway, Iceland and the United Kingdom with a long-term cooperation system with other EU countries. e.g. Spain OR Greece)
Date for searches.			Category: Feel interested, challenged and competent Code: Personal accomplishment	Feel interested, challenged and competent	Feel interested, challenged and competent	Subtheme: Personal accomplishment
Preliminary search: 5 May 2020 Main search: 8 June 2020 and 14 June 2020 (publication period last 20 years) The search was re-run before the final part of the analysis was finished: 1 October 2020 (publication period 8 June 2020 and 1 October 2020)

Table to the right, includes an example of the preliminary synthesis.

Since a sustainable lifestyle, incorporating a balanced lifestyle, is a research area that has not been studied previously within police health research, we used a theoretical model; Kielhofner’s Model of Human Occupation (MOHO) [41] to find environments and contexts interacting with the patrolling officers, thus influencing their lifestyle and health. MOHO defines a person’s life context as their physical, social and occupational environment, existing on three different levels, the immediate context (e.g. home or work), the local context (e.g. community or neighbourhood) and the global context (e.g. laws and policies). The life contexts, that is environments and contexts, moreover include environmental characteristics (environmental qualities and components) interacting with a person on each level [41].

Hence, regarding phenomena of Interest – words related to patrolling officers’ life contexts as explained by MOHO [41] were used to formulate this part of the PICo search string, see example in Table 1.

Identification, screening and eligibility

The searches were conducted between 8 and 14 June 2020, and the publication period spanned the last 20 years. The searches were re-run before the final part of the analysis was finished on 1 October 2020, using the time period between 8 June and 1 October 2020; however, no new articles were found.

Searches were performed in eight databases and then moved to RAYYAN, a web application for conducting systematic reviews [44]. The identification, screening and eligibility process, including reasons for exclusion of articles in every step, are reported in accordance with PRISMA guidelines, and described in a flow diagram, see Figure 1.

Figure 1. Flowchart according to PRISMA. ^aStudies that did not meet inclusion criteria were excluded from the review when one of the exclusion criteria was met. ^bThree of the included articles came from our personal library (other identified sources) and the rest from databases.

The first author performed the searches. As a first step, duplicates of the initial search results were removed by the same author. Screening of titles and abstracts against eligibility criteria was accomplished independently by the first and the third authors, blinded to each other, with discrepancies negotiated towards agreement. Hence, a third person was not needed to resolve disagreements.

After the first screening process, the full texts were obtained and examined for eligibility by the first author. The last author randomly selected and verified 10% of the full texts for consistency. No discrepancies were found; consequently, no third person was needed to resolve disagreements.

The study investigated different environmental characteristics of the life contexts related to patrolling police officers’ occupational role to find outcomes affecting their lifestyle and health, thus both qualitative and quantitative approaches were needed to enhance the comprehensibility of the research area. As contexts and environments were key elements in the study, the search strategy was limited to original articles; excluding editorials and other systematic reviews. Grey literature in the form of research reports was however included, to reduce publication bias [45]. Articles written in any language other than English or Scandinavian languages were excluded due to practical reasons. The reasons for excluding studies can be found in Figure 1.

Critical appraisal

The first two authors, blinded to each other, assessed the quality of all included articles using the 2018 version of the Mixed Method Appraisal Tool (MMAT) [46]. The MMAT evaluates studies with a qualitative, quantitative randomized controlled, quantitative non-randomized, quantitative descriptive and mixed methods study design. It has been used in many critical appraisals globally and is considered content validated and reliable [47,48].

The decision about the cut-off for excluding a study was decided before the critical appraisal began. The cut-off for exclusion was if the study did not have a clear research question and if the collected data did not address the research question. Any disagreements during critical appraisal were resolved through discussion; hence no third person was needed in the final decision-making. The result of the critical appraisal was also used when performing the final parts of the narrative synthesis.

Data extraction

Data extraction was performed on the selected and quality-assessed studies, using a pre-piloted data extraction sheet, including basic information about the study, participant characteristics, and measures or questions used to assess the different studies’ outcomes. In addition, data were extracted for each of the PICo search strategy tool domains: ‘Population’, ‘phenomena of Interest’ and ‘Context’. The data-extraction sheet was constructed by the first two authors, verified by the last author, pre-piloted by the first and last author, and slightly revised afterwards by the first two authors.

The first author extracted the data from the included studies into an Excel file [49]. Of the 16 articles, four randomly selected articles were extracted by the last author to check for discrepancies. No inconsistencies were found, thus no discussion with a third person was needed. Two of the extracted articles had insufficient data regarding age and gender. By contacting the authors, additional information was received regarding one of the articles.

Data synthesis

Narrative synthesis with four included elements [50] was used for analysis, allowing the authors to synthesize the data systematically.

Element 1: In line with Popay et al.’s instructions [50] theory development was conducted, using the theoretical framework of MOHO [41] as well as a life balance model (LBM) [33] to create a visualization of how the life contexts influence patrolling officers’ life balance, see Figure 2 for a simplified example of this model.

Figure 2. Patrolling officers’ life contexts and how the different contexts and environments are interconnected with the officers’ lifestyle, and thus connected to a balanced lifestyle; life balance. Included are also examples of different environments within different contexts, including ^aExamples of environmental characteristics from a previously conducted scoping review on patrolling officers’ life contexts [51].

Element 1 was performed as an initial step of the review process to understand which types of research to include in this study [50]. The model was developed by the first author and verified by the second and third authors.

Element 2: Inspired by thematic analysis, first an inductive and then a deductive approach was used [52] to develop the preliminary synthesis. Inductive coding of the findings pertaining to lifestyle was performed to meet the study’s aim. In addition, the coding from the different studies, i.e. qualitative, quantitative and mixed-method studies, was transformed, ‘qualitizing’ the codes [53] into qualitative findings (see example in Table 1).

Additionally, to address the aspect of what constitutes a sustainable lifestyle, the LBM [33,34] was used. Its emphasis is on a health-promoting balanced lifestyle because a lifestyle with greater balance contributes to overall health and resilience [33]. The LBM comprises five dimensions of life balance, including four need-dimensions: 1. ‘Biological health and physical safety’; 2. ‘Rewarding and self-affirming relationships with others’; 3. ‘Feel interested, engaged, challenged, and competent’; and 4. ‘Create meaning and a positive identity’. The fifth dimension relates to skills, namely ‘Organize time and energy to meet important personal goals and personal renewal’ [33], see Figure 2.

Hence, the codes from the thematic analysis were sorted into categories and then, with a deductive approach, thematized into the different needs and skill dimensions of the LBM (see example in Table 1). This element was carried out by the first author and verified by and conferred with the third author.

Element 3: Inspired by meta-ethnographic methods we used reciprocal translational analysis (RTA) and lines-of-argument to discover ‘a whole’ among a set of parts [54]. RTA was used to explore relationships between studies and illuminate differences in the data. RTA focuses on finding concepts, thus the thematized ‘LBM dimensions’ and codes from the thematic analysis were used. These dimensions and codes created a conceptual map and were translated into concepts to link them to one another. Then, a table of themes was created, presenting the new RTA themes, subthemes and next-level subthemes. The RTA themes are named after the LBM dimensions, representing five different findings. To explain these five findings ‘qualitative case descriptions’ were used, leading up to a linkage model.

The linkage model was created by conducting lines-of-argument [54]. Linkages between the main concepts developed from the reviewed studies were visualized, thus providing a conceptual model that met the study’s aim of what constitutes crucial areas for a healthy and sustainable lifestyle of patrolling officers. This element was carried out by the first author and discussed continuously and thoroughly with the third author.

Element 4: Assessing robustness is an important part of finalising a systematic review. Nevertheless, there is a lack of scientifically reliable and validated instruments for grading mixed-method reviews that use a narrative synthesis [50]. Therefore, ‘Confidence in the Evidence from Reviews of Qualitative Evidence’ (GRADE-CERQual), originally intended for reviews with qualitative studies [55], was chosen to assess robustness in the total body of evidence, analysed separately for every finding. The method was found most suitable since the review studied phenomena of interest, and we had qualitized the quantitative findings [53]. The method assesses methodological limitations, adequacy, relevance and coherence and enabled reflections on having quantitative data in the outcome when grading adequacy, which made the assessment possible. The element was carried out by the first author, presented to all authors, and discussed thoroughly with the third and last author.

To receive different theoretical perspectives on examining and interpreting the data, all elements in the narrative synthesis were presented regularly to all authors. The data synthesis was in all elements undertaken using MAXQDA 2020 [56] and Word [57].

Results

The search yielded a total of 1494 articles after removing duplicates, where another six articles were added manually. Following title and abstract screening, 85 studies were reviewed in full text. Finally, 16 articles reporting 13 single studies were included in the final review (see Table 2 and Figure 1).

Table 2. Peer-reviewed articles’ characteristics, research methodology, results of quality assessment and contexts.

Peer-reviewed articles’ study and population characteristics
[Article identifier] Peer-reviewed articles (N = 16)	Research context	PICo ‘Interest of phenomena’	Sample size	Population characteristics (age and sex)	Results of the quality assessment^a
Qualitative studies (n)
Focus group interviews (n = 1)
Ramstrand N, Larsen LB. Musculoskeletal injuries in the workplace: perceptions of Swedish police. Int J Police Sci Manag 2012;14:334–342. [58]	Three regions in Sweden	Police officers’ experience of, for example, wearing a uniform, utility belt, safety vest, sitting in police cars and the perceived strain this has on their bodies. Focus is on the immediate level, but includes aspects on a global level. Also, time factors are included.	33	The study included 19 males and 14 females. The average age of the participants was 33.5 years (range 25–45 years).	5/5 Yes
Quantitative studies (n)
Cross-sectional studies (n = 13)
Takken T, Ribbink. A, Heneweer H, et al. Workload demand in police officers during mountain bike patrols. Ergonomics. 2009;52:245–250. [59]	Utrecht, the Netherlands	Police officers’ physical workload during mountain bike patrol. This affects them on a physical level but also on an occupational level in relation to time elements, as well as occupation and activity choices.	20	The study included 16 males and 4 females, with a mean age of 32 + 8 years and 25 + 5 years.	2/5 Yes
Terpstra J, Schaap D. Police culture, stress conditions and working styles. Eur J Criminol. 2013;10:59–73. [60]	Southern Gelderland, the Netherlands	The culture of police officers in patrolling services. How environments affect them in different ways regarding cultural aspects, as well as how they view their profession and the public.	260	260 participated in the study. 74% were male and 20% were female. Three had missing data regarding age and gender. 5% were younger than 25 years, 30% were 25–34 years, 31% 35–44 years, 21% 45–54 years, and 9% were above 54 years.	3/5 Yes
Backteman-Erlanson S, Padyab M, Brulin C. Prevalence of burnout and associations with psychosocial work environment, physical strain, and stress of conscience among Swedish female and male police personnel. Police Pract Res. 2013;14:491–505. [61]	Police Authority, Sweden	Psychosocial work characteristics influencing patrolling police officers regarding organizational culture and climate, but also how decisions, demands and social support affect police officers.	856	The study included 419 males and 437 females. The mean age was 34 years (SD = 6.9) for females and 39 years (SD = 10.7) for males.	4/5 Yes + 1 cannot tell
Larsen LB, Tranberg R, Ramstrand N. Effects of thigh holster use on kinematics and kinetics of active duty police officers. Clin Biomech. 2016;37:77–82. [62]	A medium-sized municipality, Sweden	Police officers carrying different load carriage systems and the effect on gait.	19	The study included eight females and nine men. Average age of female and male police officers separately 32 years (SD = 4.2; range 26–41) and 34 years, respectively (SD = 4.9; range 27–40).	3/5 Yes
Padyab M, Backteman-Erlanson S, Brulin C. Burnout, Coping, Stress of Conscience and Psychosocial Work Environment among Patrolling Police Officers. J Police Crim Psychol. 2016;31:229–237. [63]	Police Authority, Sweden	Psychosocial work characteristics influencing patrolling police officers concerning social support, demands, decisions and coping methods used.	856	The study included 437 participants, of which (51%) were female and 419 (49%) were male. Age (years) female mean (34), SD (7), male mean (40), SD (11).	4/5 Yes + 1 cannot tell
Ellrich K. Burnout and violent victimisation in police officers: a dual process model. Polic An Int J. 2016;39:652–666. [64]	Lower Saxony, Germany	Police officers being victims of violence when controlling a suspect, while also being the first police officer at the scene with a colleague. The article explains police officers’ strategies and attitudes.	1931	The study primarily included male officers. (Female police officers 26.6%). The age of the survey sample ranged from 21 to 62 years, with an average age of 39.6 years.	4/5 Yes
Ellrich K. The influence of violent victimisation on police officers’ organisational commitment. J Police Crim Psychol. 2016;31:96–107. [43]	Lower Saxony, Germany	Work-related victimization of uniformed patrol police officers, and the psychological and work-related consequences. This includes, e.g. personal accomplishment, self-esteem and collaboration with a supervisor.	1931	The study included 1931 participants. 27% of the respondents were female, and 73% were male. The mean age of the survey sample was 39.6, ranging from 21 to 62 years of age.	4/5 Yes
Ellrich K, Baier D. The influence of personality on violent victimisation – a study on police officers. Psychol Crime Law. 2016;22:538–560. [65]	Lower Saxony, Germany	Police officers being victims of violence when controlling a suspect, while also being the first police officer to arrive at the scene with a colleague. This includes e.g. the match between the demand of the activity at hand and the police officer regarding both strategies and capabilities.	1813	The study included almost three-quarter males (72.6%). Respondents’ age varied between 21 years and 62 years with a mean age of 39.1 years (SD = 10.4).	4/5 Yes
Wain N, Ariel B, Tankebe J. The collateral consequences of GPS-LED supervision in hot-spots policing. Police Pract Res. 2017;18:376–390. [66]	West Midlands – Coventry and Birmingham South; England	Policing hot-spots with GPS-LED supervision compared to not policing hot-spots and the difference between the officers regarding leadership, trust and cultural aspects.	38 + 42 (80 in total)	Not specified in the article and not received from the authors.	4/5 Yes
Bürger B, Nachreiner F. Individual and organisational consequences of employee-determined flexibility in shift schedules of police patrols. Police Pract Res. 2018;19:284–303. [67]	Bavaria, Germany	Police officers’ experience of working different shifts, with different levels of flexibility, its influence on the organization and on the officers’ private lives	927	In the study 20.5% of the sample was females. Almost 51% of the participants were up to 34 years of age and around 12% were 50 years or older.	4/5 Yes
Larsen LB, Andersson EE, Tranberg R, et al. Multi-site musculoskeletal pain in Swedish police: associations with discomfort from wearing mandatory equipment and prolonged sitting. Int Arch Occup Environ Health. 2018;91:425–433. [68]	Police Authority, Sweden	Police officers’ physical work environment regarding carrying mandatory equipment, sitting in a police car and the effects it has on the officers’ bodies.	4114	Male police officers represented 75% of the participants and the majority of participants were 25–39 years of age.	4/5 Yes
Engel S, Wörfel F, Maria AS, et al. Leadership climate prevents emotional exhaustion in German police officers. Int J Police Sci Manag. 2018;20:217–224. [69]	One unspecified police department, Germany	The effects of a positive leadership climate on patrolling police officers.	941	Male officers constituted 73% of the sample and the participants were between 21 and 59 years of age.	4/5 Yes
Vera Jimenez JC, Fernandez F, Ayuso J, et al. Evaluation of the police operational tactical procedures for reducing officer injuries resulting from physical interventions in problematic arrests. The case of the Municipal Police of Cadiz (Spain). Int J Occup Med Env Heal. 2020;33:35–43. [70]	Cádiz, Spain	Police officers sustaining injuries when performing different physical interventions in problematic arrests, in relation to different education provided to the police officer.	162	The study included eight females and 154 males aged 24–55 years.	3/5 Yes + 1 cannot tell
Mixed Methods (n = 2)
Participant observation (qualitative) and Questionnaire (quantitative) (n = 1)
Kop N, Euwema MC. Occupational stress and the use of force by Dutch police officers. Crim Justice Behav. 2001;28:631–652. [42]	Two medium-sized cities in the Netherlands	Police officers’ interactions in the social environment with civilians, and the police officers’ perceptions and experience of using force.	358	The study included 83% males and 17% females, average of 32.7 years (SD = 7.70).	4/5 Yes
Descriptive survey analysed quantitatively and qualitatively (n = 1)
Maran DA, Varetto A, Zedda M, et al. Stress among Italian male and female patrol police officers: A quali-quantitative survey. Policing. 2014;37:875–890. [71]	The whole of Italy	Gender aspects of patrolling police officers as well as experience of everyday situations with colleagues and the public.	485	The study included 255 males and 230 females. The mean age of the males was 45.47 years (range 21–65). The mean age of the females was 42.55 years (range 21–59).	4/5 Yes

^aAccording to MMAT, ‘Yes’ is rated if the article reports sufficient information according to the quality criteria and ‘No’ the opposite. The ‘Can’t tell’ response category indicates that the article does not report appropriate information to answer ‘Yes’ or ‘No’, or that there is unclear information related to the criterion. Five questions are answered for every article according to the specific study design of the article [46].

Study characteristics

The included articles had different research designs: one qualitative method, 13 quantitative methods and two mixed-method studies. The years for publication ranged from 2001 to 2020. The majority of the studies were completed in Germany and Sweden, see Table 2 for detailed information on the research context, and population characteristics, as well as results from the quality assessment using MMAT. The MMAT was also used when assessing robustness in the review’s total body of evidence, see Table 3 for the GRADE-CERQual evidence profile.

Table 3. A table of themes, and an assessment of robustness table.

An overview of the LBM dimensions in the table of themes		GRADE-CERQual Evidence Profile^a
Summary of review findings:
Themes and subthemes	Studies contributing to the review findings: Subthemes [article identifier] Next level subtheme [article identifier]	Methodological limitations (MMAT score added) [article identifier]	Coherence (how clear and well supported the fit is between the data from the primary studies and the review finding)	Adequacy (an overall determination of the degree of richness and quantity of data supporting the finding)	Relevance (the extent to which the body of data from the preliminary studies supports the review findings’ applicability to the context specified in the review question)	CERQual assessment of confidence in the evidence	Explanation of CERQual assessment
1. Biological health and physical safety; ‘Physical problems and pain’ and ‘Demanding situations’	Physical problems and pain [58,59,68,70,71] Clothing and wearables [58,62,68] Being a target of violent victimization [43, 64,65,70] Demanding situations [42,61,63] Officers’ use of force and experience of violent situations [42,43,64] Officers’ perceptions of safety [60,67]	In total, minor methodological limitations. Three studies with no or very minor concerns: 5/5 Yes [58] 4/5 Yes + 1 cannot tell [61] 4/5 + 1 cannot tell [63] Six studies with minor concerns: 4/5 Yes [64] 4/5 Yes [43] 4/5 Yes [65] 4/5 Yes [71] 4/5 Yes [68] 4/5 Yes [42] Three studies with moderate concerns: 3/5 Yes + 1 cannot tell [70] 3/5 Yes [60] 3/5 Yes [62] One study with serious concerns: 2/5 Yes [59]	Minor concerns about coherence exist. The finding reflects the complexity and variation regarding biological health and physical safety. Well supported in general, while some aspects of the finding need further research. For example, officers’ perceptions of safety.	No or very minor concerns about adequacy. 13 studies contributed to this finding. We concluded that we had only minor concerns about the adequacy, based on an overall assessment of the richness of the data and the quantity of the data. Not specifically regarding quantity, because the studies included many participants. But, possibly regarding the richness of the finding in the different studies.	Minor concerns about relevance. The findings have a direct relevance regarding the micro context (time, place and population). Concerning cross-cutting and the phenomena of interest, there is only indirect relevance to this study’s aim. This is due to the fact that the studies included in the review had research aims other than what this review focuses on. The review also has only partial relevance regarding the macro context (policy and political issues), because the diverse studies were conducted in different countries with national variances.	Moderate confidence. It is likely that the review’s finding is a reasonable representation of the phenomena of interest.	The findings include 13 studies with minor methodological limitations. Regarding coherence there were only minor concerns. Concerning adequacy there were no or very minor concerns. Minor concerns regarding relevance were found related to the phenomena of interest and macro context.
2. Rewarding and self-affirming relationships; ‘Family life and social life’, ‘Social support and professionality’, ‘Leadership climate’ and ‘Challenging relationships with the public’	Family life and social life [67,69,71] Social support and professionality [42,43,60,63,66,67,71] Leadership climate [43,60,66,67,69] Challenging relationships with the public [42,60,70,71]	In total, minor methodological limitations. One study with no or very minor concerns: 4/5 + 1 cannot tell [63] Six studies with minor concerns: 4/5 Yes [69] 4/5 Yes [71] 4/5 Yes [43] 4/5 Yes [67] 4/5 Yes [66] 4/5 Yes [42] Two studies with moderate concerns: 3/5 Yes [60] 3/5 Yes + 1 cannot tell [70]	Minor concerns about coherence exist. The finding reflects the complexity and variation regarding rewarding and self-affirming relationships. Due to the fact that rewarding and self-affirming relationships in police officers’ private lives are also important, this aspect of the finding needs further research. Hence, there could be a plausible alternative description of the data that has not been found in this review.	No or very minor concerns about adequacy. Nine studies contributed to this finding. Based on an overall assessment of the richness of the data and the quantity of the data, we concluded that we had only minor concerns about the adequacy. Not specifically regarding quantity, because the studies included many participants. But, possibly regarding the richness of the finding in the different studies.	Minor concerns about relevance. The findings have a direct relevance regarding the micro context (time, place and population). Concerning cross-cutting and the phenomena of interest in the study, there is only indirect relevance to this study’s aim. This is due to the fact that the included studies have research aims other than what this review focuses on. The review also has only partial relevance regarding the macro context (policy and political issues), because the diverse studies were conducted in different countries with national variances.	Moderate confidence. It is likely that the review’s finding is a reasonable representation of the phenomena of interest.	The findings include nine studies with minor methodological limitations. Regarding coherence there were only minor concerns. No or very minor concerns were found regarding adequacy. Minor concerns regarding relevance were found, related to the phenomena of interest and macro context.
3. Feel engaged, challenged and competent; ‘Experience, education and organisational engagement’, ‘Participation regarding decision-making’ and ‘Being in control’	Experience, education and organizational engagement [42,43,60,61,66,69–71] Participation regarding decision-making and being in control [58,63,67]	In total, minor methodological limitations. Three studies with no or very minor concerns: 4/5 Yes + 1 cannot tell [61] 4/5 + 1 cannot tell [63] 5/5 Yes [58] Six studies with minor concerns: 4/5 Yes [43] 4/5 Yes [69] 4/5 Yes [71] 4/5 Yes [66] 4/5 Yes [42] 4/5 Yes [67] Two studies with moderate concerns: 3/5 Yes [60] 3/5 Yes + 1 cannot tell [70]	Minor concerns about coherence exist. The finding reflects the complexity and variation in the different studies. It is in general well supported. However, some aspects of the finding need further research; participation regarding decision-making and being in control.	No or very minor concerns about adequacy. Eleven studies contributed to this finding. Based on an overall assessment of the richness and quantity of the data, we concluded that we had only minor concerns about the adequacy. Not specifically regarding quantity, because the studies included many participants, but possibly regarding the richness of the finding in the different studies.	Minor concerns about relevance exist. The findings have a direct relevance regarding the micro context (time, place and population). Concerning cross-cutting and the phenomena of interest in the study, there is only indirect relevance to this study’s aim. This is because the studies included in the review have research aims other than what this review focuses on. The review also has only partial relevance regarding the macro context (policy and political issues), because the diverse studies were conducted in different countries with national variances.	Moderate confidence. It is likely that the review’s finding is a reasonable representation of the phenomena of interest.	The findings include eleven studies with minor methodological limitations. Regarding coherence there were only minor concerns. Concerning adequacy there were no or very minor concerns. Minor concerns regarding relevance were found related to the phenomena of interest and macro context.
4. Create meaning and a positive personal identity; ‘The use of coping strategies’, and ‘Police image, work effort and belief in the mission’	The use of coping strategies [63,71] Police image, work effort and belief in the mission [60,66,69,71]	In total, minor methodological limitations. One study with no or very minor concerns: 4/5 + 1 cannot tell [63] Three studies with minor concerns: 4/5 Yes [71] 4/5 Yes [66] 4/5 Yes [69] One study with moderate concerns: 3/5 Yes [60]	Minor concerns about coherence exist. The finding reflects the complexity and variation in the different studies. However, some aspects of the finding need further research, such as the use of coping strategies, and what it implies to lifestyle and health. Hence, there could be alternative plausible ways of describing the data, which have not been explored.	Minor concerns about adequacy. Five studies contributed to this finding. Based on an overall assessment of the richness and quantity of the data, we concluded that we had minor concerns about the adequacy. Not specifically regarding quantity, because the studies included many participants, but possibly regarding the richness of the finding in the different studies.	Minor concerns about relevance. The findings have a direct relevance regarding the micro context (time, place and population). Concerning cross-cutting and the phenomena of interest in the study, there is only indirect relevance to this study’s aim. This is because the studies included in the review have research aims other than what this review focuses on. The review also has only partial relevance regarding the macro context (policy and political issues), because the diverse studies were conducted in different countries with national variances.	Moderate confidence. It is likely that the review finding is a reasonable representation of the phenomena of interest.	The findings include five studies with minor methodological limitations. Regarding coherence and adequacy, there were only minor concerns. Minor concerns about adequacy. Minor concerns regarding relevance were found related to the phenomena of interest and macro context.
5. Organize time and energy to meet important personal goals and personal renewal; ‘Activity configuration’	Activity configuration Activity configuration congruence [42,58,59,61,68] Activity configuration equivalence [58,67,69,71]	In total, moderate methodological limitations. Two studies with very minor concerns: 5/5 Yes [58] 4/5 Yes + 1 cannot tell [61] Five studies with minor concerns: 4/5 Yes [42] 4/5 Yes [68] 4/5 Yes [71] 4/5 Yes [67] 4/5 Yes [69] One study with serious concerns: 2/5 Yes [59]	Moderate concerns about coherence exist. One aspect of this finding is not found in any of the studies, namely the ‘activity configuration equivalence’ described in the LMB model [34]. The studies did not address this aspect at all, and organizing time and energy to meet important personal goals and personal renewal was not explored in detail.	Minor concerns about adequacy. Eight studies contributed to this finding. Based on an overall assessment of the richness and quantity of the data, we concluded that we had minor concerns. Not specifically regarding quantity, because the studies included many participants, but possibly concerning the richness of the finding in the different studies.	Minor concerns about relevance. The findings have a direct relevance regarding the micro context (time, place and population). Concerning cross-cutting and the phenomena of interest in the study, there is only indirect relevance to this study’s aim. This is because the studies included in the review have research aims other than what this review focuses on. The review also has only partial relevance regarding the macro context (policy and political issues), because the diverse studies were conducted in different countries with national variances.	Moderate confidence. It is likely that the review finding is a reasonable representation of the phenomena of interest.	The findings include eight studies with moderate methodological limitations. Regarding coherence there were moderate concerns. Concerning adequacy there were minor concerns. Minor concerns regarding relevance were also found related to the phenomena of interest and macro context.

^aConfidence assessment using the GRADE-CERQual approach.

Patrolling police officers’ lifestyle and health

The RTA themes, consisting of five findings, are explained in a table of themes representing the different aspects of life balance, see Table 3. Qualitative case descriptions elaborate on these themes and subthemes, including barriers and resources for living a healthy and sustainable lifestyle. Thus, every finding in the police officers’ life contexts is combined into ‘a whole’, among a set of parts of both barriers and resources for a healthy and sustainable lifestyle. Consequently, explaining what the resources and challenges for a balanced lifestyle are. Moreover, leading up to our linkage model, see Figure 3. It should however be noted that mostly occupational resources and challenges were found, limiting the knowledge gained from the officers’ total balance in life.

Figure 3. The model shows different life contexts (including all contexts and environments in Figure 2), visualized as this figure’s background. It symbolizes patrolling officers’ balance in life through different aspects of health as described in the result section. Thus, providing insights into different barriers and resources for a healthy and sustainable lifestyle for patrolling officers. The visualized character of mental health is slightly larger, showing where most of our findings are located. The themes are numbered according to the table of themes in Table 3.

Biological health and physical safety

Sustainable patterns of occupation that maintain physiological health and safety are important for a balanced lifestyle according to Matuska and Christiansen [33]. This study’s first finding and theme include the subthemes ‘Physical problems and pain’ with two next level subthemes, as well as ‘Demanding situations’ also including two next level subthemes. Altogether, the theme includes 13 studies, representing different aspects of the theme and subthemes, where the information explaining the specific part related to the theme or subtheme is presented adjacent to the article where it was found [42,43,58–65,68,70,71]. As depicted in Figure 3, this theme touches upon aspects of both physical and mental health.

Biological health and physical safety – physical problems and pain

Five studies reported on factors related to physical problems and pain. Two studies reported on biological health in terms of musculoskeletal pain [58,68], and Maran et al. [71] reported other physical symptoms, for example, fatigue, sexual problems and feeling bloated [71]. Vera Jiménez et al. [70] found different types of injuries due to problematic arrests [70], while Takken et al. [59] reported on how bike patrol officers experience too much physical exercise during the day, which could put physical stress on their bodies [59].

Clothing and wearables

Three studies described factors concerning clothing and wearables. Ramstrand and Larsen [58] reported on the overall fit and design of the police uniform and equipment, which was reported unsatisfactory, with the duty belt being a major source of musculoskeletal injury [68]. Larsen et al. [68] found that wearing mandatory equipment was significantly associated with multi-site musculoskeletal pain, with the duty belt having the greatest association [68]. Load carriage systems were by Larsen et al. [62] reported affecting the hip joint on the side of the body on which the weapon is located and at the ankle of both left and right sides [62].

Being a target of violent victimization

Risk factors for physical safety in terms of being a target of violent victimization were reported in four studies. A risk factor found by Vera Jiménez et al. [70] seemed to be insufficient education when performing problematic arrests, which resulted in officer sick leave [70]. Also, Ellrich [64] described depersonalized officers holding a more favourable attitude towards the use of violence in interactions with civilians, as well as a positive attitude towards violence, which was found related to violent victimization. Similarly, emotional exhaustion increased police officers’ risk of being attacked, not only by a reduction in self-protecting behaviour, but it affected victimization directly [64]. Furthermore, Ellrich [43] and Ellrich and Baier [65] found officers’ personality [43,65] and civilian-related attributes [65] to play a part in officer victimization.

Ellrich and Baier [65] also found that police officers’ different personal characteristics (personalities) were relevant to victimization in dangerous situations in which violence had already occurred [65]. Furthermore, civilian-related attributes, such as drunken civilians (violent or not), as well as male civilians compared to encounters with just females or mixed groups of males and females, were reported as risk factors for violent victimization [65]. However, two articles also showed that controlling suspects were less likely to result in an attack compared to encounters due to domestic violence [43,65]. Additionally, Ellrich [43] showed patrolling officers who had been victimized also reported lower levels of organizational commitment [43].

Biological health and physical safety – demanding situations

Three studies reported on factors related to demanding situations. Kop and Euwema [42] described that emotionally demanding situations, such as work-related danger, suicide or sexual offences involving children were reported as stressors, together with other specific events, such as body searches or mediating in domestic conflicts. However, police officers mentioned organizational stressors more often than the nature of their job, for example staff shortages, bad management and reorganizations [42].

Two articles also described that experiencing high demands at work, such as stress of conscience, demand and organizational climate for females, and stress of conscience, decision and demand for males, were significant predictors for emotional exhaustion. For both male and female patrolling officers, significant correlations were found between work characteristics (demand, decision and social support) and depersonalization, and stress of conscience also increased the risk of being depersonalized [61,63], as well as showing a high correlation with burnout [61].

Officers’ use of force and experience of violent situations

Three studies reported on factors concerning police officers’ use of force and experience of violent situations. Regarding dangerous situations and the use of force, more depersonalized police officers [42,64] and officers who felt less competent [42], were found to hold a more favourable self-rated attitude towards using violence in interactions with civilians. Additionally, Kop and Euwema [42] reported that all observations of verbal and physical use of force occurred with police officers who scored high on burnout scales. Surprisingly, more personally accomplished officers were also found related to the observed use of force, but they did not self-report using more force themselves [42]. In addition, male police officers were by Kop and Euwema [42] found to use more force than female officers [42], and Ellrich [43] also reported female officers reporting violent experiences less frequently than males [43].

Officers’ perceptions of safety

Two studies described factors affecting the perception of safety. Where Terpstra and Schaap [60] reported that police officers stated that their work frequently involved danger, threats and insults but the awareness of risk and danger did not result in a fundamental distrust of strangers. Only one-third of officers felt that, in the case of risk and danger, they could only rely upon themselves, and that patrolling officers should be able to trust each other blindly [60]. Furthermore, Bürger and Nachreiner [67] reported that when the organization allowed high flexibility in scheduling it was also associated with a reduction in perceived safety at work [67].

Rewarding and self-affirming relationships with others

According to Matuska and Christiansen [33], the meaning and satisfaction of having rewarding and self-affirming relationships with others as human beings influence the perceived life balance [33]. This theme includes the subthemes ‘Family life and social life’, ‘Social support and professionality’, ‘Leadership climate’ and ‘Challenging relationships with the public’. It includes in total nine studies [42,43,60,63,66,67,69–71], representing different aspects of the theme and subthemes, where the information explaining the specific part related to the theme or subtheme is presented adjacent to the article where it was found. As depicted in Figure 3, this theme touches upon all aspects of health; physical, social and mental. However, not all subthemes are related to all aspects of health, see Figure 3.

Rewarding and self-affirming relationships with others – family life and social life

Four studies reported factors related to family life and social life. Having an employer-chosen schedule with some employee flexibility showed the highest perceived compatibility of work with social life, and the effect of the shift systems on work-life balance was highly significant [67]. Having children showed conflicting results, and was reported to be a stressor by Maran et al. [71]; but, only for females [71]. However, not by Engel et al. [69] who found that children did not have any significant impact on emotional exhaustion for either male or female patrolling officers [69]. Maran et al. [71] also described that family problems were present for both genders, with minimal differences in dealing with partners, but that low salary was more of a concern for distress for males [71].

Rewarding and self-affirming relationships with others – social support and professionality

Seven studies reported on factors affecting social support and professionality. Personally accomplished officers had a more positive attitude towards using their social skills [42]. Regarding interpersonal relations at work, Wain et al. [66] found no differences between hot-spot policing and non-hot-spot policing. Also, doing hot-spot policing did not affect interpersonal trust or the levels of support officers received from their colleagues [66]. Correspondingly, Terpstra and Schaap [60] reported that the stronger the perceived stress of the officers was, the stronger the bonding between them [60].

Furthermore, Padyab et al. [63] reported that weak social support was associated with poor psychological well-being for females [63]. Ellrich [43] found female police officers showing somewhat higher levels of social cohesion but lower self-esteem, however reporting social stressors occurring less frequently than males [43]. Different working shifts were also shown by Bürger and Nachreiner [67] to have an impact on the social structure at work, where the employer chosen schedule with no flexibility had the highest negative impact, followed by a shift system with some flexibility, and an entirely employee flexible schedule showing the lowest impact on the social structure at work [67].

Ellrich [43] found police officers to be more committed to their organization when they reported group cohesiveness. Group cohesiveness also moderated the association between civilian-related violence and organizational commitment [43]. Furthermore, Maran et al. [71] reported that officers’ experienced lack of cooperation and being unprofessional produced critical situations. These aspects of cooperation and professionalism were found specifically important for female officers [71]. Likewise, Terpstra and Schaap [60] described officers with a relatively strong service or professional orientation more often experiencing respect and authority from the public [60].

Rewarding and self-affirming relationships with others – leadership climate

Five studies were found to explain leadership climate. Engel et al. [69] reported a positive leadership climate to reduce emotional exhaustion and buffer the negative impact of work effort [69] whereas Ellrich [43] described that when the officers had immediate supervisor support, organizational stressors were no longer associated with organizational commitment [43]. Likewise, important determinants of organizational commitment were found to be immediate supervisor support and having a leadership role position at work [43].

Terpstra and Schaap [60] described that the majority of the police officers were displeased about the support given by management at a distance or to management as a general idea, not with their closest supervisor [60]. However, Wain et al. [66] found hot-spot officers to be more likely to believe that their supervisors did not have their best interests at heart or treat them fairly, for example seldom offering explanations for decisions that affected the officers [66].

Regarding scheduling shift work, Bürger and Nachreiner [67] reported that a schedule with total flexibility was associated with losing work-related social structures, and drawbacks concerning, e.g. leadership. This did not occur within an entirely employer-based shift system, or a shift system with some flexibility, which provided comparable positive results [67].

Rewarding and self-affirming relationships with others – challenging relationships with the public

Four studies reported factors concerning having a challenging relationship with the public. Vera Jiménez et al. [70] reported on police interventions which resulted in injury and sick leave of police officers; examples included disobedience, insults, threats, resistance and attacks [70].

Furthermore, Maran et al. [71] found that behaviour and reactions of the public were reported as stressors, for example not being respected for what they do or the need to find solutions to the public’s problems [71]. Police officers also stated that they felt that the general public’s respect for the police was declining, which made it harder for them to maintain authority [60]. Different styles of policing also revealed different problems associated with respect and authority in their relations with the public [60]. According to Kop and Euwema [42], there was also clear scientific support for a relationship between burn-out and negative attitudes towards civilians.

The nature of police work was furthermore by Kop and Euwema [42] cited as stressful, especially emotionally demanding situations regarding the public [42].

Feel interested, engaged, challenged and competent

An important component of a balanced lifestyle according to Matuska and Christiansen [33] includes opportunities to feel competent and engaged through occupations that are interesting and challenging. This contributes to identity and creates meaning in life [33]. In this review, this theme includes the subthemes ‘Experience, education and organizational engagement’ and ‘Participation in decision-making and being in control’ and consists of 11 studies in total [42,43,58,60,61,63,66,67,69–71]. The theme and subthemes represent different aspects, where the information explaining the specific part related to the theme or subtheme is presented adjacent to the article where it was found. This theme touches upon all aspects of health; physical, social and mental (see Figure 3). However, not all subthemes are related to all aspects of health, as depicted in the figure.

Feel interested, engaged, challenged and competent – experience, education and organizational engagement

Eight studies reported on factors related to officers’ experience, education and organizational engagement. Ellrich [43] found that female officers as a group had a lower level of work experience and were reported to have a higher job position less often compared to male officers. Female officers also experienced fewer organizational stressors [43]. Maran et al. [71] reported that stressors of not having enough effective means of intervention to solve serious social problems were found for females, while for men working with colleagues with little experience and who do not seem to recognize signs of danger were found more stressful [71].

Emotional exhaustion was also reported higher in officers with greater length of service and at a middle level (compared with upper-middle) career stage [69]. However, Backteman-Erlanson et al. [61] showed that depersonalization decreased with age for both females and males [61]. Furthermore, Kop and Euwema [42] reported that officers with more work experience were found to have a less negative attitude towards civilians [42]. However, these officers were also described to be more conservative and have a greater dislike towards intellectual pursuits according to Terpstra and Schaap [60], while also showing a decline in interest for action and excitement in police work and the view of associating police work with physical strength [60]. Additionally, the same officers showed less organizational commitment, according to Ellrich [43]. Despite this, Kop and Euwema [42] reported that officers who felt less competent were also found to hold a more favourable attitude towards violence in interactions with civilians [42].

One of the most important determinants of organizational commitment was by Ellrich [43] found to be organizational tenure [43]. Self-esteem was in the same study also found significantly positively related to organizational commitment, but a more important determinant of organizational commitment was found to be personal accomplishment [43]. When Wain et al. [66] compared hot-spot police officers and non-hot-spot police officers, no differences in terms of organizational commitment were found; however, hot-spot officers were statistically less likely to believe their values were similar to those of the organization [66].

Vera Jiménez et al. [70] found a reduction in patrolling officers’ injuries when performing interventions in problematic arrests during a time when police operational-tactical procedures (OTP) training was provided to officers, compared to a time when no OTP education was provided [70].

Feel interested, engaged, challenged and competent – participation regarding decision-making and being in control

Three studies found factors affecting participation regarding decision-making and being in control. Significant correlations between emotional exhaustion and work characteristics (demand, decision and social support) were reported by Padyab et al. [63]. Furthermore, Bürger and Nachreiner [67] found shift work to be an important factor affecting the compatibility of work with social life. A shift work schedule with some flexibility, where police officers can make some of their own choices regarded when to work, seemed to offer the highest perceived compatibility with social life, even though employee flexibility was greater in a different shift system [67]. Ramstrand and Larsen [58] also described that not being able to make personal choices about clothing, duty belt, personally suited safety vests and footwear, or when to exercise during work hours, were raised as stressors [58].

For females, low control, together with stress of conscience, were the significant predictive factors for depersonalization, indicating that a higher risk of depersonalization is associated with less control in the work environment, as well as a guilty conscience. Females also showed significantly higher scores on stress of conscience than men, and work seemed more stressful for female police officers [63].

Create meaning and a positive identity

This theme refers to the importance of creating a life purpose to be resilient in stressful conditions, according to Matuska and Christiansen [33]. It includes the subthemes ‘Police image and belief in the mission’ and the ‘Use of coping strategies’ and includes five studies in total [60,63,66,69,71]. The theme and subthemes represent different aspects, where the information explaining the specific part related to the theme or subtheme is presented adjacent to the article where it was found. As depicted in Figure 3, this theme only touches upon aspects of mental health.

Create meaning and a positive identity – police image, work effort and belief in the mission

Four studies found factors related to the police image, work effort and belief in the mission. Engel et al. [69] reported that officers who reported high work effort were found to be significantly more emotionally exhausted than others [69].

Furthermore, Terpstra and Schaap [60] described that the image of police work to the officers was closely related to physical strength and courage. A powerful sense of mission to maintain norms of good and bad, and to protect the weak was also important to some officers. For other officers, it was found to be the personal attraction to action and excitement [60]. Self-legitimacy was by Wain et al. [66] found to be equal between hot-spot and non-hot-spot police officers. However, hot-spot police officers held fewer positive attitudes towards hot-spot policing [66].

Also, as a consequence of being a police officer in relation to the public, the public needs to obey rules. This sometimes results in upset and negative behaviours or reactions from the public, which was found stressful for the officer according to Wain et al. [66]. Furthermore, Maran et al. [71] described another stressor, when police officers had different views on the profession or when colleagues might cause trouble due to unprofessional behaviour [71].

Create meaning and a positive identity – the use of coping strategies

Only two studies reported on factors related to the use of coping strategies. Coping strategies were found by Padyab et al. [63] to vary between sexes and were also differently correlated to depersonalization depending on if they were used more or less. For example, ‘psychological distancing’ and ‘wishful thinking’ were found to be correlated to emotional exhaustion [63]. Maran et al. [71] reported on coping strategies used to deal with stressors, across genders, including active coping, planning and acceptance. However, emotional support, venting and religion were used more by female officers than by their male counterparts. Males used problem-solving coping strategies such as active coping, planning, instrumental support, positive reframing and humour as a way to cope with stressors [71].

Organizing time and energy to meet important personal goals and personal renewal

According to Matuska and Christiansen [33] to meet the needs of life, people must manage the multiple demands on their time sufficiently to accomplish goals and renew their energy. Thus, organising time and energy to meet important personal goals and personal renewal [33]. One’s actual activity configuration (for definition see Matuska and Christiansen [33]), incorporates both equivalence and congruence in everyday life, and should also match one’s desired activity configuration [34].

The theme in this study consists of the subtheme ‘Activity configuration’ incorporating both ‘Activity configuration equivalence’ and ‘Activity configuration congruence’. The theme consists of in total eight studies [42,58,59,61,67–69,71] and represents different aspects, where the information explaining the specific part related to the subtheme is presented adjacent to the article where it was found. As depicted in Figure 3, this theme touches upon all aspects of health; physical, social and mental.

Organize time and energy to meet important goals and personal renewal – activity configuration

Congruence

Factors related to configuration congruence were found in five studies. In one study officers reported being in contact with civilians for about 25% of their time during an 8-h shift. The rest was spent on desk work or meetings [42].

Females were also found to do more natural exercise and high activity exercise than men. Strength exercise was the same for both, and they reported an equally high proportion of low-strength exercise [61]. Larsen et al. [68] reported that the majority of officers were found to do physical exercise more than two hours per week, but over 80% also reported sitting in police vehicles for 25–75% of their average work shift. This sedentary lifestyle at work was, however, not related to musculoskeletal pain according to Larsen et al. [68]. For bike patrol officers, Takken et al. [59] found that too much time was spent on physical exercise during their workday [59]. Likewise, Ramstrand and Larsen [58] described factors regarding the police officers’ need for physical training at work and flexibility around when to train was also raised as a concern [58].

Equivalence

Four studies found factors related to the configuration equivalence. Ramstrand and Larsen [58] described fatigue and not having time to rest related to work hours was identified as a potential risk for health when not getting enough rest between shifts. Likewise, overtime and sleep problems were discussed as potential risk factors for ill-health [58]. Emotional exhaustion was by Engel et al. [69] reported being affected by multiple factors, such as the length of service, a fixed schedule (compared with a flexible schedule), lower age, part-time (compared with full-time) employment, without involvement in operations (compared with involvement in operations) and at a middle level (compared with upper-middle) career stage [69].

When comparing diverse shift systems Bürger and Nachreiner [67] found differences in work and social life between officers working the three different shift schedules. The entirely flexible shift work system and the shift work schedule with some flexibility had the best positive effect on work-life balance, but the shift work schedule that had the best compatibility regarding well-being, social life, work climate and leadership was the system with some employer flexibility [67].

Ramstrand and Larsen [58] reported time-consuming aspects of work, such as not having time to adjust poorly fitted duty belts, as perceived stressors [58]. While Maran et al. [71] added the aspect of colleagues who spend time doing other things instead of doing their job, or officers having to spend time fixing colleagues’ errors, as a raised stressor at work [71].

Conceptual model of patrolling officers’ sustainable lifestyle and health

A model explaining how the identified crucial areas within patrolling officers’ life contexts influence their lifestyle and health, thus implicating barriers and resources for a balanced lifestyle (see Figure 3). The model visualizes how the different themes touch upon one or several different aspects of health; social, physical and mental, previously described in the qualitative case descriptions. Findings related to ‘Activity configuration’ touch upon all aspects of health.

Assessing robustness

The robustness of the total body of evidence is assessed for every finding in the review. Findings are presented on the level of themes in the study, see Table 3. GRADE-CERQaul’s evidence profile is included to show transparency regarding the assessment. The MMAT assessment is one part included in the evidence profile, summarized for every finding, respectively. Also, ‘coherence’ is assessed, where minor to moderate concerns were found for the different findings. Having quantitative data in the total body of evidence did not seem to have an impact on the robustness. Except for ‘adequacy’, where all five findings separately had quite many participants due to the quantitative data. Minor concerns regarding ‘relevance’ were found related to the phenomena of interest and macro context. All together the assessment showed moderate confidence in the review’s findings and is considered a reasonable representation of the phenomena of interest. However, it should be noted that the findings are built as parts of a larger concept. As separate studies included in each finding have for example minor to serious methodological concerns, which have been noted in Table 3, the findings should not be interpreted as separate entities, but as a whole, explaining crucial areas for a healthy and sustainable lifestyle of patrolling officers using a model of life balance to describe barriers and resources for living a balanced lifestyle.

Discussion

Many of the crucial areas for a healthy and sustainable lifestyle identified in this review touch upon barriers and resources for a balanced lifestyle contributing to knowledge regarding patrolling officers’ physical, mental and social health. The areas found were mostly within their work-life, where different aspects of health might be disturbed, depending on the barriers and resources to life balance that the patrolling officers are experiencing. Examples from different aspects of life balance include ‘physical problems and pain’, ‘social support and professionality’, ‘experience, education and organizational engagement’, ‘police image, work effort and belief in the mission’, as well as ‘activity configuration’.

Previous reviews have synthesized different aspects of police officers’ health [6,16,23,35]. However, this systematic review complements earlier findings by exploring specifically patrolling officers, as well as the research area of life balance. This novel area adds to existing police health research by contributing to understanding and knowledge of patrolling officers’ lifestyle and health. Nevertheless, mostly barriers were found, probably due to the biomedical paradigm where the focus is predominantly on illness, excluding a more holistic view of health [72].

Physical, social and mental health were all found to be affected by ‘Organizing time and energy to meet important personal goals and renewal’. This gives us incipient information regarding patrolling officers’ ‘activity configuration’, e.g. how time is spent at work, as well as off work. But also, what the challenges might be concerning health. For example, how shift systems and overtime affects the patrolling officers’ health. This finding is in line with previous research since much research has been conducted on the effect shift work has on physical [73] and mental health [74]. However, our findings do not tell us if the equivalence or congruence is low or high regarding activity configuration.

Time also influence all the other life balance dimensions, creating a contextual background that affects what a person does and what meaning it has to them, according to Matuska and Christiansen [33]. Consequently, to explain the effect time has on officers’ lifestyle and health, more research is needed into the different life contexts of patrolling officers. For example, how shift work also impacts patrolling officers’ private lives and social health. Since none of the included articles were time-use studies, the lack of investigation into this finding was not surprising. A previous research report focussed on the time-use and time management of police officers during a typical shift [75]; unfortunately, aspects of health were not included in that report.

The physical health of the officers was, in this review, found to be affected by various domains of life balance. Examples include aspects of ‘Biological health and physical safety’, and some aspects referring to ‘Rewarding and self-affirming relationships’ and ‘Feeling engaged, challenged and competent’.

Physical health is considered a human right [76], and findings from a meta-analysis of different workers show that prevailing physical symptoms are related to a wide range of job stressors [77]. Thus, the focus must be put on preventive actions involving organizational development for patrolling officers, with regards to minimising ‘physical problems and pain’, as well as receiving organizational support in ‘challenging relationships with the public’ and ‘demanding situations’. Consequently, promoting a healthy workplace would be important, both regarding ‘clothing and wearables’, but also regarding the reasons for ‘use of force and experiencing violence’, as well as ‘being a target for violent victimization’. Here, ‘experience, education and organizational engagement’ is of key interest, because a good education is one way to show support for the officers within these areas. According to Matuska and Christiansen [33], the need for biological health and physical safety is considered a key dimension to achieving resilience and a health-promoting lifestyle [33]. Hence, by emphasizing organizational interventions for police officers [78], their well-being and service delivery to the public will likely be improved, since organizational stressors also impact officers’ performance at work [79].

The review’s most important finding is the domains affecting the patrolling officers’ social health. We found ‘rewarding and self-affirming relationships’, and aspects of ‘feeling engaged, challenged and competent’ to touch upon the social health of the officers. Examples include aspects of ‘leadership climate’, ‘family life and social life’ as well as ‘social support and professionality’, together with officers’ feeling of ‘participation regarding decision-making and being in control’. Thus, these crucial areas are important to consider for Police Authorities in Europe and are also in line with a previous review which found patrolling officers residing in many different social environments during their workday [51], making officers’ social health an important aspect to focus on for future research.

The importance of feeling participation at work regarding certain aspects affecting both work and private life, as well as having supportive leadership and functioning relationships between colleagues are presented in the findings. Together with struggles regarding social life and family situations when working as a patrolling officer. This finding is supported by previous research, where for example work-family conflict has been found associated with later sickness absence, especially common for females experiencing the ‘double burden hypothesis’ [80]. Furthermore, Matuska and Christiansen [33] describes the importance of social support considering physical and mental health benefits. Thus, the finding in this review has both organizational and individual benefit. Correspondingly, international research on police officers’ work-life balance shows the importance of Police authorities supporting officers’ work-life balance [15].

Unfortunately, on the whole, this review includes only a few articles where the private lives and social health of police officers were investigated. Previous studies have indicated that police work affects marital relationships negatively [8], causing secondary trauma [81]. Also, engaging in communication within marriage is important to have a healthy relationship [82]. Likewise, lack of hobbies and social support in officers’ private lives has previously been found to predict mental ill-health after trauma [83].

In total, many different barriers were found to explain the lifestyle and mental health of the researched officers. For example, emotional exhaustion, personal accomplishment and depersonalization were researched in different ways. These aspects of burnout affect, or were affected by, for example the use of force, high demands at work, different coping strategies used by the officers, victimization and different time factors. Previous research conducted on policing supports the effect police work has on officers’ mental health, indicating that it is one of the most stressful occupations [35].

Together with a high degree of organizational stress, policing may also place officers in instantaneous life-threatening contexts in which they have to make crucial decisions. These high-risk situations may affect officers’ stress levels, even after the incidences, impacting their health [35]. Thus, considering how important ‘creating meaning and a positive identity’ is for resilience during stressful conditions according to Matuska and Christiansen [33], this domain would be important to consider to support patrolling officers' health. For example, previous research has shown that specific goals, self-efficacy and feedback increase officers’ job motivation. These extrinsic motivational factors lead to job satisfaction [84]. In turn, the link between job satisfaction and both the mental and physical health of workers has been well established [85]. Emphasizing the importance of creating meaning and a positive identity also for police officers.

Furthermore, resources that enable police officers to ‘feel interested, engaged, challenged and competent’ were found concerning the patrolling officer’s mental health. Occupational therapy and science support this finding by indicating that people who are successful in performing their occupations in life are empowered to meet their roles [86]. This develops mastery, which increases competence and self-efficacy [33,86]. Self-efficacy is central and has previously been found to support job motivation for officers [84].

The findings of this review contribute to the emerging research field of police officers’ lifestyle and health since the review synthesizes barriers and resources for living a healthy and balanced life. However, the review cannot provide enough evidence to explain all resources patrolling officers need to live a healthy and sustainable lifestyle. We argue that exploring the life balance of patrolling officers is an important area for the future, including both professional and private life contexts. For example, qualitatively exploring their patterns of daily occupations, where both work and private life contexts are included on similar terms.

Strengths and limitations of the review

This review is strengthened by the synthesis of both qualitative and quantitative research studies, enabling a comprehensive incipient understanding of patrolling officers’ balance in life, and connection to health. Compensating for the inherent challenges of mixing quantitative and qualitative data, we followed a systematic procedure to ensure a transparent and comprehensive review process.

However, some limitations should be considered. Studies exploring a sustainable lifestyle or life balance for patrolling officer do not exist. Thus, to be able to research the topic, we adopted a broad approach using free text searches, focussing on their life contexts and locating outcomes related to a LBM within occupational science. However, when creating the search algorithm to identify patrolling officers, we chose to exclude the word ‘policing’. The word is a common keyword within police practice research. Consequently, using the keyword would include an abundance of irrelevant studies. Nevertheless, it should be considered a limitation, since studies focussing on police health research might have been missed, resulting in an insufficiently sensitive search string. Also, studies with higher-ranking officers and officers not doing patrol duty, as well as specialized units within patrolling services were excluded. Hence, we excluded an abundance of studies irrelevant to our study’s aim, nevertheless possibly also excluding relevant articles. However, it gave us more control over the population in the study, which should be considered a strength.

It should also be noted that the review did not have two separate reviewers in all the conducted steps, due to practical reasons. To mitigate this, another reviewer, verified 10% of the data for inconsistencies. Although none were found, it should still be considered a potential bias. Also, the review included 16 articles based on 13 studies. Since some articles include the same participants, it may have influenced the results. This was not possible to adjust for in this synthesis, but it should be noted as a probable bias.

The findings included European studies only, hence it might be difficult to generalize the findings, at least outside of Europe. It should also be noted that countries within Europe are diverse, incorporating Police Authorities with national differences. Despite this, the work is similar, especially within the democratic countries included in the review. And, although findings are preliminary, they do not appear country-specific and are supported by previous international studies on police officers’ health. Nevertheless, this possible limitation was considered when assessing the robustness of the review.

Assessing robustness using GRADECerqual was a novel approach for this type of review, and should also be considered a limitation. However, assessing robustness is an important stage of a systematic review, and excluding this important part from the review due to a lack of appropriate measures, would have weakened our review. This approach also assessed the fact that some studies had few participants, considering this aspect when assessing the total body of evidence for each finding.

Conclusions and clinical implications

Several crucial areas were identified and described indicating barriers and resources for a healthy and sustainable lifestyle. However, the areas found were primarily within their work-life and are inchoate. So, future research will be needed to further answer our research questions.

However, patrolling officers’ working life affects the possibilities for living a balanced lifestyle, disturbing different aspects of health, depending on which aspect is compromised. By gaining more knowledge regarding patrolling officers’ life contexts and how contexts and environments affect their lifestyle and health, we will be able to understand what further promotes these officers’ balance in life. Continuing to explore patrolling police officers’ patterns of daily occupations, including how they balance these occupations, is thus important, due to the challenging contexts they encounter. It is possible, that by exploring these patterns in life and the connection to health, creating and providing occupational therapy interventions for patrolling officers would be possible. Therefore, focussing on a sustainable lifestyle and health would likely improve their resilience, making it easier to avoid sick leave and stay longer within patrolling services. Having resilient officers when they perform in high-risk situations is essential since it also provides high-quality police work to the public. This should however be studied further.

Ethics approval and consent to participate

As this research did not involve the collection of data from human subjects, formal ethical approval was waived.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The search results supporting this systematic review are from previously reported studies and datasets, which have been cited. The saved articles are available at RAYYAN from the corresponding author on reasonable request. Data have been extracted to an Excel file. All data generated and analysed during this study are included in the published article, and Supplementary files are available on reasonable request.

Additional information

Funding

The study is, from the design of the study, collection, analysis and interpretation of data, including the writing of the manuscript, funded by the Department of Community Medicine and Rehabilitation at Umeå University, Sweden. The funding body had, however, no role in the preparation of this manuscript.