Organizational Factors and Their Impact on Mental Health in Public Safety Organizations

Public safety personnel (PSP), including correctional officers, firefighters, paramedics, and police officers, have higher rates of mental health conditions than other types of workers. This scoping review maps the impact of organizational factors on PSP mental health, reviewing applicable English language primary studies from 2000–2021. JBI methodology for scoping reviews was followed. After screening, 97 primary studies remained for analysis. Police officers (n = 48) were the most frequent population studied. Correctional officers (n = 27) and paramedics (n = 27) were the second most frequently identified population, followed by career firefighters (n = 20). Lack of supervisor support was the most frequently cited negative organizational factor (n = 23), followed by negative workplace culture (n = 21), and lack of co-worker support (n = 14). Co-worker support (n = 10) was the most frequently identified positive organizational factor, followed by supervisor support (n = 8) and positive workplace culture (n = 5). This scoping review is the first to map organizational factors and their impact on PSP mental health across public safety organizations. The results of this review can inform discussions related to organizational factors, and their relationship to operational and personal factors, to assist in considering which factors are the most impactful on mental health, and which are most amenable to change.


Introduction
Public safety personnel (PSP) work to maintain the safety of civilians and help communities in need [1]. When the terms PSP or first responder are used, the public often think of highly visible occupations, such as correctional officers, firefighters, paramedics, or police officers. While these professions are key stakeholders in the PSP population, it is important to recognize the many other PSP roles including border services officers, rescue personnel, operational intelligence personnel, and communications operators/dispatchers [2,3]. All PSPs take on job demands related to protecting the public, whether it is on the front lines or behind the scenes. Throughout this review, the variety of job demands that PSP face will be referred to as public safety work.
The duties, tasks, and roles associated with public safety work, also thought of as the content of the work, has the potential to expose PSP to psychological trauma [4]. The literature suggests that there is a relationship between PSP work and mental health conditions. Diagnoses including posttraumatic stress disorder (PTSD), depression, anxiety disorders, and substance use disorder, along with suicidal ideation, stress, and burnout, are commonly seen in this population, often at higher rates than the general public [1,4,5].

Impacts of Operational, Personal, and Organizational Factors on PSP Mental Health
There are common operational, personal, and organizational stressors and facilitators that interact with one another to both stress and facilitate the mental health of PSP.

Search Strategy
The search strategy located published primary research studies. An initial limited search of PsycInfo and MEDLINE, on the Ovid platform, was undertaken to identify initial articles on the topic. The text words in the titles and abstracts of these relevant articles, and the index terms used to describe the articles, were then used to develop a full search strategy for MEDLINE. This search strategy, including all identified keywords and index terms, was adapted for each included information source or database (see Appendix A for a sample search strategy).

Information Sources
The databases searched were Embase, PsycInfo, and MEDLINE, on the Ovid platform, as well as Web of Science on the Clarivate platform, and CINAHL on the Ebsco platform, to ensure a broad search for relevant studies.

Study Selection
Following the search, all identified citations were collated and uploaded into the Covidence platform, which removed duplicates. Titles and abstracts were screened by four independent reviewers and assessed against the inclusion criteria for the review, using Covidence. Potentially relevant studies were retrieved in full, and their citation details imported into Covidence for further review. The full text of selected citations was assessed in detail against the inclusion criteria by the same four independent reviewers. The reasons for exclusion of full text studies not meeting the inclusion criteria were recorded and reported in Figure 1. Disagreements that arose between the reviewers at any stage of the study selection process were resolved through discussion, or with a fifth reviewer. The results of the search are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram ( Figure 1) [16].
in detail against the inclusion criteria by the same four independent reviewers. The reasons for exclusion of full text studies not meeting the inclusion criteria were recorded and reported in Figure 1. Disagreements that arose between the reviewers at any stage of the study selection process were resolved through discussion, or with a fifth reviewer. The results of the search are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram ( Figure 1) [16].

Data Extraction
Data was extracted from articles included in the scoping review by four independent reviewers using a data extraction tool developed by the reviewers. The data extraction tool was in table format and included columns for the population, concept including personal, operation and organizational factors, context and additional details, study methods and key findings relevant to the review objective. Disagreements that arose between the reviewers were resolved through discussion, or with the fifth reviewer.

Data Extraction
Data was extracted from articles included in the scoping review by four independent reviewers using a data extraction tool developed by the reviewers. The data extraction tool was in table format and included columns for the population, concept including personal, operation and organizational factors, context and additional details, study methods and key findings relevant to the review objective. Disagreements that arose between the reviewers were resolved through discussion, or with the fifth reviewer.

Study Inclusion
After the initial search, 13,543 articles were found, with deduplication, 11,437 remained, with 684 of these meeting screening criteria. After full-text access and review, 587 articles that did not meet inclusion criteria were eliminated, leaving 97 articles for inclusion in this review ( Figure 1). Table 1 outlines the study characteristics and factors of the 97 papers that were identified through the search process. 60 percent (n = 58) of the papers were published in the last five years. Most included studies were conducted in North America: United States (n = 43) and Canada (n = 19). Other included studies were conducted in the United Kingdom (n = 19), Australia (n = 16), and New Zealand (n = 2). One study was conducted within Australia and the UK, another within the United States, Canada, and Europe, and another included Canada and the United States. Two-thirds of the studies utilized cross-sectional research designs emphn = 62). Qualitative (n = 15) and cohort studies (n = 5) were the next most frequent study designs. Other study designs included: longitudinal (n = 4), mixed methods (n = 4), quasi-experimental (n = 3), case-control (n = 2), and randomized control trial (n = 1) designs. Finally, one study measured the psychometric properties of a measurement tool.

Operational, Organizational and Personal Factors
While the literature search focused on organizational factors, operational and personal factors were frequently reported by the same papers and so were also captured during data extraction. Table 1 also outlines the positive and negative operational, personal, and organizational factors found in the included studies. Below are the most common factors extracted from the 97 articles included in this scoping review. Numbers in [brackets] refer to the article identification numbers of Table 1. Please note that some articles reported on organizational factors, but the factors were deemed neither positive nor negative (e.g., neutral factors or factors without evidence of impact). These articles are included in the review as they met inclusion criteria but may not have data noted in Table 1 related to positive or negative organizational factors.

Positive Factors Positive Operational Factors
Operational factors are considered to be the unavoidable aspects of public safety work, sometimes referred to as the content of the work. Two articles identified a positive relationship between work role and mental health outcomes [93,100]. For example, police officers working in "Operational Support" roles demonstrated lower odds of developing PTSD compared to investigations officers [100]. In another study, correctional workers in Institutional Governance (e.g., superintendents, and correctional managers) had higher mean PTSD scores than those working in Institutional Wellness (e.g., nurses, social workers, psychologists, etc.) [93]. Furthermore, participants working in institutional correctional services demonstrated higher problematic alcohol use scores than participants working in Institutional Wellness, Institutional Administration (e.g., administrative assistants), and Community Supervision Officers (e.g., parole and probation officers) [93]. Department setting (n = 1) was another positive operational factor; working in suburban, urban, and mixed departments was associated with a lower risk of depression, PTSD, and suicidality scales compared to rural departments [56]. Finally, in one study, tenure and rank showed a positive relationship with PSP mental health [56,82].

Positive Personal Factors
Personal factors refer to factors unique to the individual performing the public safety work; these factors exist outside of the work context but may interact with it. Out of the 97 included studies, family support (n = 8) [5,18,21,41,45,46,48,77] and job satisfaction or meaning (n = 8) [5,19,26,43,77,100,105] appeared to be the most frequent supportive personal factors. For example, one article emphasized the protective role of family relationships in preventing correctional officers from attempting suicide [48]. Regarding job satisfaction and meaning, another article identified police officers as obtaining satisfaction through contributing positively to the lives of civilians in disaster-struck communities [22]. Indigenous correctional officers found meaning in supporting the rehabilitation of Indigenous prisoners [90]. Four articles listed work/life/family balance (n = 4) [27,43,46,105] and gender (n = 4) [22,71,79,106] as supportive personal factors. In one article, female PSPs reported lower levels of PTSD compared to their male counterparts [22]. Adequate sleep (n = 3) [27,42,100], including sleep quality and sleep duration, demonstrated a positive influence on PSP mental health in three studies. Several positive coping skills (n = 3) [46,83,85] were noted, including going for long walks, participating in yoga and meditation, accessing psychological supports, doing exercise, abstaining from alcohol, detachment from work issues, problem-solving, pondering, and lack of effective rumination [43,46,83]. Resiliency (n = 3) [8,75,108] was associated with lower secondary traumatic stress in PSP populations [75]. Finally, good physical health (n = 3) [43,76,85], race (n = 3) [71,82,106], and social support (n = 3) [18,29,101] were other identified positive factors.

Factor Frequencies
After completing the extraction of the 97 articles and determining meaningful characteristics of the data, this scoping review gathered a total of 607 positive and negative factors within the operational, personal, and organizational factors found in PSP organizations ( Table 2)

Discussion
In the completion of this review, the frequency of factors, trends across countries, specificity of factors to PSP groups, and the amenability of organizational factors to change were most notable and will be discussed below. Table 2 shows the frequencies of the negative and positive operational, personal, and organizational factors discussed in the evidence outlined in this scoping review. Based on these frequencies, negative factors (n = 470) were much more prevalent than positive factors (n = 137). This could be a result of how the studies were constructed; researchers may have found that discovering the barriers impeding PSP mental health is a more pressing issue to discuss as opposed to the positive aspects of public safety work. It is also possible that negative factors and stressors are more commonly seen in PSP organizations than positive factors and facilitators to mental health.

Factor Frequencies
This review focused on discovering what organizational factors exist in public safety organizations and how the frequency of organizational factors compare with personal and operational factors. It is interesting to note that personal factors, both negative and positive, were more commonly seen (273 times) than organizational factors (208 times). Personal factors accounted for a total of 45 percent of factors found, which was often due to studies reporting mental health conditions (n = 26), issues of work/life/family conflict (n = 19), physical health and sleep concerns (n = 33), as well as demographic factors (n = 12). Because the focus of this review is on organizational factors, the impact of personal factors will not be discussed in further detail but the factors themselves can be found within Table 1 for further information.
Comparing all the factors that were discussed, organizational factors accounted for 34 percent with operational factors at 21 percent, respectively. This data shows that the context and content of public safety work may be responsible for over one half of the factors influencing PSP mental health, and therefore public safety organizations have impactful opportunities to change these factors.

Trends across Countries
Another trend to consider from this scoping review is the frequency of PSP research in each country. In our review we found that North America (United States and Canada) was the primary region that PSP research was being recognized and conducted. Policing, firefighting, and corrections were being studied primarily in the United States and Canada, whereas other PSP professions such as paramedics and EMTs were being studied primarily in Australia. There has been limited research in communications officers and dispatch throughout all the countries investigated in this review. Canada, the United States and the United Kingdom were the most frequently cited countries in this review, therefore, the recommendations mentioned below may be most applicable to these countries.
In this review, negative organizational factors were most commonly studied in the United States. These studies frequently found a lack of supervisor support, negative workplace culture, limited access to resources to do the work, lack of co-worker support and various shiftwork models as negative organizational factors in PSP organizations. Stigma was seen most in Canadian studies and leadership issues were most prominent in the studies from the United Kingdom. This may indicate more attention to these issues in these countries, rather than an increased presence of the issues in these places.

Common Operational and Organizational Stressors Impacting PSP
Given that the content and context of the work performed within public safety organizations is a potential focus for employers related to mitigating risks to their employees, the most frequent operational and organizational factors will be discussed by career type, in order of their frequency of appearance in this review.

Police Officers
Negative public perception of career [5,20,30,37,44,69,70,82] and risk of injury [3,5,20,35,43,50,69,70,82] were the primary operational factors negatively impacting police officer mental health outcomes. Loughran [113] explained that a string of recent high-profile cases of police violence may have eroded public perception of police legitimacy. Negative public image is an organizational stressor police officers frequently face [110]. Increased public scrutiny and animosity towards police negatively impact individual encounters between officers and citizens. Poor interactions with the public can worsen police officers' mental health outcomes [37].
In terms of organizational factors, workplace culture was the most frequently encountered negative factor. Demou et al. [37] identified that police officers in particular "are afraid of being identified as individuals who have been compromised by stress" (p. 703). Coworker support [26,37,39,43,45,46,49,75,77,85] and supervisor support [23,39,45,47,49,62,67,85] were the most frequently cited positive factors. These factors were included more often than any other factor. Dollard et al. [39] explained that in workplaces with a high psychosocial safety climate, police officers know they will be supported in the face of unexpected demands (e.g., attending a fatal shooting or vehicle accident). This support can improve coping ability, which serves a protective role against negative mental health outcomes [39]. The findings of this review were congruent with a 2017 literature review of police stressors and their impact on health [8], which showed that both mental and physical health impacts were associated with organizational stressors in police organizations.

Correctional Officers
Operational factors were not as commonly identified in the articles found for correctional officers. Articles listed psychological demands [25,29] and high workload as negative operational factors. Perceived threat to safety [72] and role [93] were the only operational factors identified which positively influenced mental health outcomes for this population.
Workplace culture was the most frequently identified negative organizational factor for correctional officers [5,38,41,80,81,92,105,112]. Dugan et al. [41] noted that correctional officers operate in a masculine culture, where personnel are expected to display strength and control and suppress emotions. Several participants in the Norman & Ricciardelli [80] study identified management as the source of toxic workplace culture. They elaborated that leadership engaged in deception and deceit with their employees, leading many to leave meetings with headaches and in tears [80]. Stigma and barriers to seeking help [5,32,38,48,67,89,90] and understaffing [5,32,45,80,81,90] were the next organizational factors negatively impacting mental health outcomes. Clements & Kinman [32] explained that "the reporting of mental health challenges is stigmatized in 'macho' types of work" (p. 444). This leads correctional officers to under-report stress [32]. Interpersonal conflict with a colleague was also a source of stress [5,25,65,80]. Support from coworkers [26,45] and supervisors [45,67] were the primary positive organizational factors for COs. Buden et al. [26] suggested that workplace social support (from coworkers and supervisors) promotes health behaviour change (e.g., increased sleep duration). Autonomy [45] and access to mental health specialists [48] were also positive organizational factors. A systematic review of correctional officer job stress and burnout [114] also showed the strong impact of workplace culture on mental health for correctional officers.

Paramedics and EMTs
High workload [36,73,74,85,96,98] and incidents involving children [22,77,85,86] were the most frequently included negative operational factors. Sofianopoulos et al. [98] identified that paramedics are, "constantly and increasingly faced with difficult clinical cases and workload that are taxing physically, mentally, and emotionally" (p. 2). Mahony [74] described how a reduction in the number of on-road paramedic crews, combined with increased emergency call volumes, has led to a process of work intensification in the UK context. This results in paramedics having little to no down-time between calls, where they would typically decompress back at the station [74]. Department setting and rank [56] were the only operational factors included which positively influenced paramedic mental health.
Limited resources to perform the work [73,77,88,91,96] was the most common organizational factor negatively impacting paramedic and EMT mental health. Similar to firefighters, Mahony [73] identified that paramedics were, "constantly pushed to achieve more with less resources" (p. 141). Lack of control over resource provision also negatively influences PSP mental health [73]. Navarro Moya et al. [77] further explained that economic crisis has resulted in significant cuts to resources. Workers may dissociate themselves from their role when an organization does not provide the necessary economic or emotional resources [77]. Lack of breaks while working [73,74] and other models of shift work [40,98] were additional organizational stressors, included in two articles each. Regarding positive organizational factors, coworker support [77,85] appeared most frequently. Supervisor support [85], role clarity [96], a 12-h shift model and a 14-h shift model [56] were also included. Organizational and operational factors faced by paramedics and EMTs did not differ significantly. A 2019 systematic review [7] focused on ambulance personnel showed how operational and organizational factors can interact to amplify job stress, and the value of supervisor support and positive leadership, supporting the current findings of this review.

Firefighters (Career and Volunteer)
Regarding negative operational factors, exposure to critical incidents [5,18,63,90] was the most frequently cited factor. Langtry et al. [64] noted that firefighters described feeling "locked in" a cycle of perpetual traumatic exposure. Firefighters are often expected to return to an "operationally ready" state after returning from an emergency deployment [64]. Armstrong [19] suggested that providing positive reinforcement after critical incidents might buffer this stressor. Department setting and rank [56] were the only positive operational facilitators identified.
Limited resources to perform the work [5,76,82,91,95,96] was the most frequently identified negative organizational factor. Smith et al. [96] identified that line-of-duty operations (such as firefighting) are expected to be performed flawlessly despite limited available resources. These expectations elicit strain on firefighter mental health. Smith et al. [96] further explained that providing adequate resources would alleviate stress and burnout. Interpersonal conflict with colleagues and supervisors [76,82,91] were the next factors negatively impacting firefighter mental health outcomes. In terms of positive organizational factors, safe work practices [97] and various models (e.g., 12, 14, 48 h) of shift work [27,56] were considered. No differences in organizational/operational factors were observed between career and volunteer firefighters. A recent meta-analysis of the impact of organizational support [115] has shown that attending to working conditions can improve employee well-being, supporting the relevance of attending to firefighters' resources to perform their duties, as well as the interpersonal aspects of their work.

Communications Officers and Dispatchers
In terms of negative operational factors, exposures to critical incidents [5,24], administrative duties, and negative public perception of career [5,91] were the next most frequently associated with communications officers' and dispatchers' mental health. There were no positive operational factors identified in the literature for this population, but the literature overall for this PSP group was limited (n = 8).
Workplace stress [101], lack of support from supervisors [47,91,101] and coworkers [47,75,90] were the primary negative organizational factors faced by communications officers and dispatchers. Galbraith [47] suggested that call and dispatch departments have different expectations for leadership than operational police officers. This study identified that managerial support was severely lacking, poorly impacting personnel's mental health outcomes [47]. Birze et al. [24] explained that communications officers, "must regularly balance and control their emotional reactions, both in themselves and others" when taking calls, dispatching, and interacting with co-workers or supervisors (p. 426). Communications officers, therefore, engage in surface acting, which involves, "hiding unsuitable feelings and faking inauthentic-yet organizationally prescribed feelings" [24] (p. 426). However, surface acting with colleagues and supervisors and colleagues was associated with higher reported PTSD symptoms [24]. Stigma and barriers to seeking help [5,90] were also negative organizational factors. Supervisor support [47] was the only positive organizational facilitator included. A recent qualitative study of public safety communications professionals [116] showed that leadership, supervision and workplace culture are key factors in the well-being of this PSP group, further supporting the findings of this review.
Other PSP workers (e.g., border services officers, rescue personnel, operational intelligence personnel) were not found with enough frequency by this review to analyze them in detail by profession, and were under-represented overall within the literature found.

Factors Amenable to Change
Ricciardelli et al. [9] point out that organizational factors (e.g., job context) in comparison to operational factors (job content) were higher sources of stress and seen to be avoidable factors in a PSP context. The operational risks of PSP duties generate stress and anxiety in workers, but, since they are often inherent to the job, they can be unavoidable. The amenability to change of organizational and operational factors were also considered by Carleton et al. [5] in assessing the impact of work stressors on PSP, and are worthy of further consideration here. Of all the factors found in this review, evidence suggests that supervisor support, leadership styles, shift work models, staffing levels, stigma, and workplace culture are just some of the characteristics of PSP organizations that may be amenable to change.

Supervisor Support
Supervisor support appeared frequently within this review [25,[30][31][32][33]43,44,47,50,59,70,71,73,77,[80][81][82]88,91,92,98,101,111]. Vaughan et al. [117] highlighted how supervisor support can be improved in PSP organizations by establishing closure for workers, empowering immediate supervisors, and changing the organizational culture. These changes may differ in each organization or discipline but overall, supervisors must consider the needs and long-term mental health status of their workers. For example, Stanley et al. [118] concluded that supervisor social support (top-down mental health promotion) could be beneficial to the health and well-being of firefighters. Additionally, immediate supervisors can be empowered to advocate on behalf of their workers for more support services, and they can incorporate increased cultural awareness in recruitment and ongoing training [117].

Leadership Styles
Leadership [5,30,31,37,43,57,73,77,81,82,86] in PSP organizations is presumed to mold the efficacy within the organization, improve the behaviour of the employees, and increase outputs for the agency [119]. With leadership style having such potential impact, leadership is important to address, potentially by implementing a development program for leaders. Leadership development programs should promote practices that focus on support strategies and visions of empowerment to increase engagement from the employees and supportive work resources [120]. However, one of the major barriers to implementing successful leaders and leadership processes includes the cultural, structural, and political aspects of the organization [119]. To implement changes in leadership style that are sustainable and effective, it is important to first address these higher-level underlying barriers that underly the organization.

Shift Work Models
Shift work [19,24,29,40,53,77,78,82,84,85,98] appeared frequently within this review, and can create difficulties for PSP as they may promote lack of sleep, which can further increase the risk for disease and/or workplace injury [8,9]. Changing the way shift work is implemented, such as adapting the schedule to also consider the PSP's personal and family needs may decrease negative health outcomes [121]. The length of a shift could be changed to provide more desirable outcomes for the PSP and the organization they work for. For example, Amendola et al. [17] found that there was a benefit to implementing 10-h work shifts over 8-or 12-h work shifts. When 10-h work shifts were implemented, PSPs reported a higher quality of life during work and increased sleep overnight. They also found that when completing 10-h shifts, employees completed less overtime, which could potentially be a cost-saving strategy as well. With increased hours of sleep, PSPs may see a reduced risk of mental health challenges and/or workplace injury. Given the variety of work contexts for different PSP groups and the lack of current conclusive evidence to promote a singular shift model, organizations might look to their employees and their unions to understand worker needs and preferences.

Staffing Levels
Staffing levels were identified frequently within this review as an important organizational factor [5,32,45,74,77,[80][81][82]90,91,96,108]. Ricciardelli [9] recommended that promoting work-life balance and allowing more time-off must be encouraged as both preventative and reactive measures to reduce work overload and stress among PSP workers. The challenge with this change is the need for more funding to improve staffing shortages. If PSPs are not given the opportunity to take needed breaks, they may be more susceptible to unexpected stress leaves, placing added pressure on the remaining staff [122]. The combination of work overload and limited organizational staffing may contribute to burnout amongst all staff members and increased organizational costs overall, making these factors a priority for change.

Stigma and Workplace Culture
The stigma surrounding accessing mental health resources or treatment is another barrier in PSP organizations that can negatively impact the mental health of PSPs [5,32,35,[37][38][39]43,48,49,51,67,77,89]. Vaughan et al. [117] found that organizations could see positive results with workplace culture that emphasizes the mental health of their staff. Given that lack of supervisor support was the most frequent negative organizational factor, and co-worker support was the most frequent positive organizational factor, efforts to improve workplace culture, reduce stigma, and provide organizational supports could all contribute to an improvement of this area [5].

Limitations
This study used a scoping methodology, and thus, the rigour of the included sources was not evaluated. Additionally, it is possible that searching a separate set of databases, or a different date range, may have identified additional sources, and relevant sources may not have been identified if search terms were not present in the abstract, title, or keywords. Due to the Anglocentric nation inclusion criteria and focus on English language papers, the results of this review are likely most relevant in English-speaking contexts. Finally, the literature search included the years 2020 and 2021, in which the COVID-19 pandemic occurred, meaning that more current sources may have included the impact of the pandemic in their results.

Conclusions
Of the 97 studies found in this scoping review, most of them represented North American contexts, and focused on police officers, followed by correctional officers, paramedics, and career firefighters. With research gathered from the years 2000-2021, the pace of publication was most brisk in the last 5 years. Overall, among all PSP groups, lack of supervisor support was identified as the most common negative organizational factor while co-worker support was identified as the most common positive organizational factor.
Although the aim of our review was to discover organizational factors among PSP groups, personal factors were present at the highest frequency in the literature found, followed by organizational factors. It is also of note that negative factors were more prominent overall than positive factors, which may indicate how studies are being constructed as well as the challenges of public safety work itself. It is clear based on the evidence that mental health challenges among PSP populations are complex and multifaceted as they are a result of the interactions between operational, personal, and organizational factors.

Future Research
Findings from this review will allow PSP, their unions, and public safety organizations to better understand the impact of organizational factors on PSP mental health. Additionally, this review has revealed gaps in existing research that can inform future studies in this domain. A similar review of non-Anglocentric countries could be completed to allow for comparison of these factors in public safety organizations across cultural contexts.
Evaluation of the studies was beyond the scope of this review and is recommended in future reviews to understand the impact of organizational factors as this body of research continues to expand. Additionally, a model of organizational factors could be created and tested against mental health outcomes for public safety organizations and is a planned next step for this group of researchers.

Conflicts of Interest:
The authors declare no conflict of interest. (("work environment" or workplace or "work place" or "work force" or organizational or Organisational or institutional or union or work*) adj2 (trust* or honesty or fairness or culture or value* or belief or believes* compassion* or satisfaction* or burnout* or stress* or attitud* or promotion* or understanding or polic* or leadership* or factor* or consequence* or bullying or theor* or behaviour* or behavior* or framework* or development* or communication* or engagement* or micromanagement or workload* or fatigue or resilience or control* or autonom* or conflict)).ab,kw,ti.