Introduction

First responders are defined as emergency frontline workers and comprise emergency health personnel such as emergency doctors and nurses as well as defense force, fire, ambulance, and police personnel. First responders may work in paid, retained (on-call), or voluntary roles or a mixture of these. The first responder role necessitates being first on the scene of an emergency and therefore involves frequent and repeated exposure to potentially traumatic events. These events are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition,1 as experiencing or witnessing actual or threatened death, serious injury, or sexual violence and can be experienced directly. The first responder, however, experiences the event themselves or indirectly, through witnessing the event happening to another person or learning that a friend, family member, coworker, or someone around them has experienced such an event.2,3 Such potentially traumatic events vary in type, intensity, and frequency depending on the job role and can leave a lasting impression on the first responder.2-4

First responder police officers, firefighters, search and rescue personnel, defense force, medical technicians, and paramedics are commonly male.2 It is only over the past few decades that females have increasingly entered male-dominated first responder roles such as police, firefighter, and ambulance personnel5 with the proportion of females in these occupations ranging from 4% to 32%.6,7

For the purposes of this protocol, the term "female" will refer to both biological sex and identified gender. Sex incorporates physiological and biological features that define humans as male, female, or intersex, based on chromosomal characteristics. Gender relates to the roles and behaviors that society generally considers appropriate for women, men, and gender-diverse persons.8

How females navigate male-dominated, first responder occupations is not well understood. The limited available evidence on females in male-dominated professions shows that females tend to adopt male behaviors, values, and attitudes over time9,10; however, the implications of this in relation to workforce retention, job satisfaction, and overall health and well-being are unclear.

The exception to this rule is first responder nursing (which is not male-dominated), and includes flight nurses, rural/remote area nurses, and emergency departments (retrieval teams), where the vast majority are female (90%).11 A systematic literature review of occupational stress in emergency department staff (generally female-dominated) determined that these staff may experience higher levels of anxiety, depression, or burnout than other hospital staff due to high work volumes and time pressures.12 The review identified quality of support and relationships with colleagues and managers to be important factors in managing stress (including compassion fatigue), suggesting that this may be one of the protective factors in relation to the retention of female first responders.3,12,13

There are relatively few studies that focus on female first responders with family responsibilities. One study showed military deployment to be particularly challenging for female personnel with dependent children.14 These females, however, also displayed high levels of resilience in the way they navigated the demands of motherhood while deployed.14 Studies have also noted high levels of compassion fatigue in first responder populations. This is particularly relevant to females who have been found to experience higher levels of emotional involvement than males, which is strongly linked to compassion fatigue and burnout.15,16 Work-family balance research has identified that workers are more committed and have greater job satisfaction when this balance occurs, which is an important area to further understand.17

Other risk factors that may impact on the retention of female first responders in this workforce include workplace stress, childhood and lifetime trauma and disorder, gender disparity, poor work-life balance, parenting, relationship and childcare difficulties, and violence and bullying.18 For emergency service volunteers, equipment issues (eg, lack of, difficulty maintaining, older equipment), leadership difficulties/disharmony within teams, erratic management/supervision styles, not feeling valued in the role, and inadequate management of fatigue19,20 create a further burden, with these factors potentially impacting males and females in distinctly different ways.

In contrast, there are also a number of protective factors that have been identified to promote retention, including supervisor support, interactional justice, recognition, and group cohesion, all of which significantly contribute to great volunteer satisfaction and ongoing commitment to the agency.21

In summary, while there is extensive research examining factors influencing recruitment and retention in the first responder workforces overall, its relevance to female first responders remains unclear due to few sex/gender-specific findings.3,4 Given the growing number of females entering these roles, both in Australia and internationally, there is a need to better understand how organizations can address specific issues and challenges facing female first responders and support their health and well-being from a workforce policy and management perspective. Factors that hinder (ie, barriers) and factors that foster (ie, facilitators) the recruitment and retention of female first responders will be considered as part of this review.

A preliminary search of the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports did not identify a systematic review on this topic. Studies specifically focusing on the health and well-being of female first responders is limited; therefore, available literature including female-only first responder studies and studies that include females within an overall first responder sample (majority male) will be explored within this systematic review.

A mixed methods approach will be used, as it allows a more comprehensive and in-depth exploration of factors that influence recruitment/retention than one type of evidence can offer. This information can provide valuable evidence regarding the factors influencing recruitment and retention of females into this workforce. Information obtained from this review will add to the currently limited evidence base on female first responders and the factors influencing their role.

The objective of this systematic literature review is to produce a set of integrated findings of qualitative and quantitative evidence to inform policy and practices relevant to the recruitment and retention of female first responders

Review question

What barriers and facilitators contribute to female first responders' recruitment and retention (including departure) in the workforce?

Inclusion criteria

Population

This review will consider studies including female first responders over the age of 18 years in the voluntary or paid first responder workforce. This will include first responder workforce groups such as police, fire, ambulance, and other emergency response teams. Studies that include references to both male and female first responders, and any studies including female first responders only will be selected. Any studies not including females will be excluded. It is likely that some studies will analyze data from first responder populations that include males and females but, due to small numbers of females in the overall population, do not provide data for males and females separately. Results from these studies will be included in a separate section at the end of the review due to their probable, but not definite, association with female sex/gender.

Studies focused solely on male-only first responders (including those where the percentage of female first responders is so low they are not reported in the statistical information) and those including first responder data from participants under the age of 18 years will be excluded.

Phenomena of interest

This review will consider studies that investigate barriers and facilitators to recruitment and retention of female first responders.

Context

The review will consider studies that investigate factors that influence the recruitment and retention of female first responders within an emergency response setting, including voluntary and paid workforces. This will include government and non-government organizations located within metropolitan, regional, and rural areas, with no geographical or socioeconomic restrictions.

Types of studies

This review will consider qualitative, quantitative, and mixed methods studies. Quantitative studies will include descriptive, cross-sectional, and longitudinal studies, causal-comparative research, and correlational research. Qualitative studies will comprise any study designs including, but not limited to, studies utilizing phenomenology, grounded theory, ethnography, action research, descriptive, and feminist research.

Mixed methods studies will only be considered if data from the qualitative or quantitative components can be easily extracted. Only studies published in the English language from 2009 to the present will be included. The year 2009 has been selected as studies on female first responders have become more readily available over the past 10 years due to government policies to increase female recruitment to this workforce.22

Methods

The proposed systematic review will be conducted in accordance with JBI methodology for mixed methods systematic reviews.23

Search strategy

The search strategy aims to locate both published and unpublished studies. An initial limited search of MEDLINE and CINAHL has been undertaken. The text words contained in the articles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (PubMed; Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists for all studies selected for critical appraisal will be screened for additional studies.

The databases to be searched include MEDLINE (PubMed), CINAHL (EBSCO), PsycINFO (APA), PTSDpubs (formerly PILOTS; ProQuest), Embase (Elsevier), and Scopus (Elsevier). The search for unpublished and gray literature will include Google Scholar, and ProQuest Dissertations and Theses Global.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full-text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported during the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.24

Assessment of methodological quality

All quantitative and qualitative papers will be assessed by two independent reviewers for methodological validity prior to inclusion in the review, using standardized critical appraisal instruments from JBI SUMARI.25

Authors of papers will be contacted to request missing or additional data for clarification where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative and tabular form.

All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). The overall methodological quality of included studies will be considered in the analysis of the integrated quantitative and qualitative findings.

Data extraction

Quantitative and qualitative data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tools in JBI SUMARI. The data extracted will include specific details about the populations, study methods, phenomena of interest, context, and outcomes of relevance to the review question. Specifically, quantitative data will comprise data-based outcomes of descriptive and/or inferential statistical tests. Qualitative data will comprise themes or subthemes with corresponding illustrations, and will be assigned a level of credibility.

Any disagreements that arise between reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data where required.

Data transformation

The quantitative data will then be converted into "qualitized data." This will involve transformation into textual descriptions or narrative interpretation of the quantitative results in a way that answers the review question.

Data synthesis and integration

The review will follow a convergent integrated approach, according to the JBI methodology for mixed methods systematic reviews using JBI SUMARI.23 This will involve assembling the qualitized data with the qualitative data. Assembled data are categorized and pooled together based on similarity in meaning to produce a set of integrated findings in the form of line of action statements.

Acknowledgments

Ms Maureen Bell, visiting research fellow, School of Psychology, The University of Adelaide, for her support in developing the literature search strategy.

The systematic review contributes towards a PhD award for HF.

Funding

This research has been made possible through the Phoebe Chapple Memorial PhD Scholarship, funded by the Australian Medical Women's Research Fund (AMWRF) Snowdrops Hope for Post-Traumatic Stress Committee, an affiliate of The Road Home and The Hospital Research Foundation. This scholarship has been supported by the South Australian State Government. The funders do not have a role in the review process.

Appendix I: Search strategy

MEDLINE (PubMed)

References