The promotion of injury and illness prevention and reporting in the fire service

2.1 Design

We used a cross-sectional survey design with a qualitative data analysis approach. This study was approved by the Institutional Review Board at Indiana State University.

2.2 Procedures and participants

To participate in this study, participants were required to be an active, career firefighter serving as a fire chief. For the purpose of this study fire chiefs were defined as the officer in charge of a municipality’s fire department [11]. Participants were excluded from the study if they self-reported as a volunteer firefighter, or a non-active/retired fire chief. Participants were recruited through the IAFC. The IAFC is the professional organization representing fire chiefs worldwide. We contacted the members of IAFC via a third-party list manager (INFOCUS Marketing, Inc., Warrenton, VA, USA) with a recruitment e-mail that contained the link to the instrument. The web-based instrument (Qualtrics Inc., Provo, UT, USA) was sent to 2,469 members of the IAFC in July 2018 and open for active collection for one month.

A total of 54 fire chiefs (male = 50, female = 4) completed the instrument. The average age of participants was 51±8 years. The participants had an average of 7±6 years of experience as a fire chief. The types of communities participants described working in consisted of 15% (n = 8) in rural communities, 54% (n = 29) in suburban communities, 22% (n = 12) in cities, and 9% (n = 5) in metropolitan areas. The fire chiefs oversaw an average of 192 firefighters (min = 0, max = 1,200). Pseudonyms were created for each of the 54 participants to maintain their anonymity. Demographic information about the fire chiefs and the departments they lead can be found in Table 1.

The instrument used in this study was developed to describe the promotion strategies in place, or lack thereof, related to injury/illness prevention and reporting behaviors in the fire service. As there was no existing instrument to meet our project objective, the researchers created a list of possible open-ended items. The instrument was developed with an emphasis on the fire service using previous literature [1, 10]. Following initial instrument development, a panel of three experts in tactical athlete healthcare analyzed each item for content validity. Following content validation, a pilot test was completed with a local fire department’s battalion chief (n = 3). We used feedback from the expert panel of healthcare providers and battalion chiefs to modify and finalize the instrument.

The final instrument contained 11 items with six items (Table 2) focusing on the specific aims of the study and five items related to participant demographics. Participants were asked their age, sex, years of experience as a fire chief, number of firefighters they oversee, and the type of community they serve. The first item asked if their fire department had an established health and wellness program with a yes/no prompt that led to open-ended response items dependent upon the participant’s response. The next five items were open-ended response boxes for participants to describe their promotion behaviors as a fire chief.

We calculated statistics of central tendency for the demographic items, and analyzed the six open-ended response items using the consensual qualitative research (CQR) tradition [12]. The process of CQR includes a 3-person qualitative data analysis team using a multi-phased process to build a consensus codebook. Data credibility was established with multiple analyst triangulation and internal auditing.

First, the codebook was created by the coding team (SLW, ZKW, LEE) based on trends in the participants’ responses [12]. Second, preliminary coding was performed by the primary researcher (SLW), which consisted of coding the first 20 lines of data of each item within the instrument [12]. Third, the coding team discussed any disagreements in how the data had been coded [12]. Fourth, the remainder of the data was coded by the primary researcher (SLW). The completely coded data was sent back to the rest of the coding team (ZKW, LEE) for review [12]. Finally the coded data set was sent to an internal auditor (KEG) for final analysis and approval [12]. Following internal auditing, the appropriate changes were made to the coded data. Frequencies were calculated for the demographics and the coded data was counted for each participant. The frequency data (Table 3) was represented using previous research methods with general indicating a term that applied to all or all but one response (53-54) [12]. Typical indicates the category applies to at least half of the responses (27–52) [12]. Variant indicates the category applies to at least than half of the responses, but more than 10 (10–26) [12]. Rare responses characterized as less than 10 (0–9) [12].

3.1 Resources

Fire chiefs discussed various resources they have access to and have implemented within their department. Based on these results, guidelines, active education, and personnel are the three most common factors used to promote reporting and prevention of injuries and illnesses.

Guidelines captured all responses pertaining to the use or implementation of policies and procedures to the current health and wellness program and to promoting injury and illness reporting and prevention. Chief Holt explained how the NFPA guidelines were followed in the creation and implementation of the health and wellness program in his fire department:

Only three fire chiefs reported having some form of guidelines in place when it came to promote the reporting of mental illness. Of these three, they did not provide clear descriptions of how they work to promote mental illness reporting. Chief Hatcher stated, “We are currently working on a health and safety po-licy and program, which will give injury and illness prevention more legitimacy.” Most responses discussed how guidelines are being used in the current health and wellness program; however, some discussed the lack thereof.

Participants described education efforts as being both active and passive. Active education included any form of education that required participation or engagement in an activity or conversation [13]. Act-ive education involved online courses, employee as-sistance programs (EAP), debriefing sessions, and in-person training sessions. Chief Cooper reported, “Our safety officer presents monthly discussions about potential accidents and prevention practices” regarding the active education avenues his department used to promote musculoskeletal injury prevention. Chief Thompkins reported the following regarding the promotion of mental illness prevention within his fire department in the state of Virginia:

Passive education included forms of education that did not require participation or engagement in activities or conversations [14]. Passive education was primarily comprised of emails, posters or flyers on display. Passive education was used comparably between musculoskeletal and mental illness reporting and prevention efforts. However, passive education was used much less frequently than active education. Chief Turner stated that one way in which his department promoted mental illness reporting was by “[posting] flyers around the station for mental health support.” Although active education was used more frequently compared to passive education, many fire chiefs described using both forms of education to promote injury and illness prevention, reporting, and treatment strategies.

The time and incentives category identified res-ponses that fostered the use of motivators to promote injury and illness reporting and prevention. Many fire chiefs described the allocation of time at work to imp-rove firefighter health and wellness to promote injury and illness prevention and reporting. Chief Vaughn described how time for fitness was allocated on each shift, as well as how the department is working to further motivate firefighters to improve their wellness, by offering a monetary incentive for being in good health:

Chief Bush discussed how his fire department allocates time each shift to promote injury prevention by implementing a warmup routine:

Time and incentives were described less frequently than other categories under the resource’s domain. However, the responses offered indicate that allocating time for physical activity and affording opportunities for further achievement may be effective in the promotion of injury and illness reporting and prevention.

Personnel was recognized as a category through responses that emphasized the availability and use of various personnel in their health and wellness programs and in the promotion of injury and illness rep-orting and prevention. Chief Serrano discussed how he works to promote mental illness reporting within his department:

Chief Jackson explained how his department hired an athletic trainer and has seen a significant reduction in injury occurrence since the employment of that team member:

Availability of various personnel primarily consisted of diverse healthcare providers that has been described by many fire chiefs as being a driving force in promoting health and wellness within their department. The participants that described working with various healthcare professionals indicated that they have seen an improvement in overall health and wellness of their firefighters.

The next category identified responses that indicated there were facilities and equipment available to the firefighters for health and wellness prevention programming by either the fire department itself or in the community. Chief Gardner expressed how the firefighters in his department are using wearable technology to track their daily exercise and fitness over time:

Many of the other fire chiefs that participated in the present study described the type of fitness facilities and amount of equipment their employees had access to while on shift to enhance their physical fitness and overall wellbeing. Chief Quinn spoke about partnerships they have built with local resources to improve firefighter wellness: “Physical fitness [is] required each shift, the city gym [is] available 24/7, partner with [a] local major University to offer [one-on-one] fitness and nutrition programs.” While facilities and equipment were not described by the participants as frequently as other categories under the resources domain, it was indicated that facilities and equipment play a vital role in allowing firefighters to participate in physical activity. Thus, providing access to facilities and equipment can improve the promotional efforts of reporting and prevention of injuries and illnesses.

3.2 Culture

Fire chiefs identified two areas of cultural involvement in the promotion of injury and illness reporting and prevention: the implementation of a supportive culture and magnitude of the stigma of being a firefighter and fear of repercussions from being viewed as weak. Fire chiefs discussed promoting the use of a supportive environment or positive change in culture within the fire department to effect change and promote reporting and prevention of injuries and illnesses. Chief Carter reported that he is working to increase the promotion of mental illness reporting by “encourag[ing] them to report even the small injuries, because they could become more serious later.” Chief Campbell discussed the progression of training the firefighters in his department receive and the multitude of avenues they have access to when they identify it is time to seek further help:

Many fire chiefs reported that they use positive encouragement toward various health and wellness practices such as proper workouts, stretching, and nutrition to encourage a positive culture to promote prevention of musculoskeletal injuries. Firefighters have created a stigma for themselves as being “tough guys” and the public has facilitated this stigma by viewing firefighters as “heroes” [8]. However, the negative stigma has had an adverse impact on the firefighting community regarding reporting of injuries and illnesses with many fire chiefs sharing that the fear of reporting injuries and illnesses may appear “weak” in the eyes of their peers or additional repercussions. Chief Patel discussed his efforts in creating an encouraging and supportive environment and the fear of reporting injuries and mental illnesses:

Chief Harris described the susceptibility of firefighters to mental health illnesses and recognized that they need to be treated on an individual basis for better outcomes:

The use of a supportive culture was described far more frequently than stigma and fear by the participants indicating a cultural shift within the firefighting community. Implementing a supportive and encouraging culture within a fire department has been described to improve reporting by firefighters which can lead to improved health and wellness of those firefighters.

3.3 Barriers

Fire chiefs identified several barriers to promoting injury and illness prevention and reporting among their employees. These barriers were described as im-pediments to either the firefighters, fire chiefs, or both. Utilization and insufficiencies were described by the fire chiefs as the two greatest barriers.

Participants rarely identified the knowledge barrier. A lack of knowledge could have been from the firefighters not knowing the proper channels or process of reporting for example, or a lack of knowledge of the fire chief. Chief Baldwin reported a lack of knowledge from the employee standpoint as a barrier to reporting musculoskeletal injuries: “There is a standard reporting [form] for the city. All employees are aware of the form. Not all employees understand where to send the reports.” Knowledge was only des-cribed as a barrier to promoting injury and illness reporting and prevention once throughout the entire data set. Therefore, knowledge is not seen as a significant barrier to injury reporting and prevention promotion.

The budget barrier identified responses that indicated the reason for a lack of efforts was due to financial limitations of any kind. Chief Ford reported budget can be a barrier in the reporting of injuries because of workers compensation denying the claims they submit: “We require reporting of all injuries. However, we have had multiple denials by worker’s comp[ensation].” Chief Spencer discussed the compromise employees may take in order to cover the cost of reporting injuries that require further medical care: “In our state, workers compensation only covers 2/3 of the employee’s pay, but we allow the employee to contribute 1/3 of the time from the vacation or sick pay.” In Chief Spencer’s example, firefighters and their families may encounter a financial barrier if they do not have enough vacation time or sick leave accrued. However, budget was only described as a barrier three times throughout the instrument, therefore, it may not be a significant barrier to promoting reporting and prevention efforts.

Time was identified as a barrier in responses that indicated a lack of time as a reason for insufficient efforts in promoting reporting and prevention. Time constraints could involve the chief not having time to find and implement new strategies, or a lack of time for the firefighters to act on the implemented strategies. Chief Byrd reported the following regarding time as a barrier to promoting musculoskeletal injury reporting and some of the difficulties associated with this topic:

Time was also only described as a barrier once in the entire data set. Therefore, time cannot be described as a significant barrier to promoting injury and illness reporting and prevention in the fire service.

The utilization barrier indicated under-utilization of pre-existing programs and resources. Chief Brady mentioned: “I have not been able to get employees to take their own mental health seriously.” Indicating that employees are not utilizing the resources they do have access to. Meanwhile, Chief Sparks reported that underutilization of available medical care can be a barrier to the reporting process for musculoskeletal injuries:

The participants did not heavily describe utilization of programming. However, it is critical that fir-efighters are able to utilize the programming they have available to them in order to improve their own health and wellness and to perpetuate the continued implementation of such programs.

Fire chiefs described their current programming efforts as being insufficient or absent. Insufficiencies could pertain to a lack of effort to promote from the fire chief, complete absence of a program, or lack of enforcement of programs that are in place. Chief Wells reported the following as a barrier to reporting mental illnesses within his fire department:

Chief Dawson stated that he does not differentiate between injuries and illnesses which can leave one to believe that they are handled in the same manner:

A few fire chiefs reported not having any way to promote the prevention of injuries within their department. Some of these chiefs did indicate that they have already recognized this insufficiency and are currently working to rectify the problem by creating a program to implement in the future. Similar responses were given regarding the promotion of mental illness prevention. However, fire chiefs provided less detail regarding future development of programs related to mental illness compared to musculoskeletal injuries.

4.1 Resources

The NFPA 1500 provides recommendations and standards for fire departments regarding occupational safety, and health and wellness programs [10], however, these recommendations are simply a suggested guideline to assist fire departments in improving the health and wellness of their employees [3]. The NFPA 1500 standard suggests that fire departments adopt an official written occupational health and wellness policy, and training, education, and professional development programs that identify goals and objectives specifically for the prevention of accidents, injuries, illnesses, and fatalities [10]. Health and wellness programs are to be created and implemented on an individual basis. Each fire department should have direct access to a physician who should oversee the health and fitness of all firefighters within the department [10]. Departments are required to provide access to behavioral health programs for both firefighters and their families with the intention that the program is used regarding any issue that could adve-rsely affect the firefighter and their support network [10]. Our study showed that fire chiefs are working to create new health and wellness, and education programs and improve existing programs to promote injury and illness reporting and prevention. Numerous fire chiefs reported implementing guidelines, many of which directly referenced the NFPA 1500 standards. Our study also demonstrated that a majority of fire chiefs in our sample claimed to implement and follow some form of guidelines (n = 43/54; 80%) and active education or training (n = 39/54; 72%) which may also attribute to the increase in overall health and wellness of the firefighters.

The WFI launched by the IAFF and IAFC aims to improve the mental, physical, and emotional strength of firefighters to enhance the longevity of their careers [4]. The WFI provides a template from which fire departments can adapt to fit their own setting to im-prove their health and wellness programs [4]. Many fire chiefs reported barriers, such as budget constraints and underutilization of current programming, to implementation which interfered with their abilities to provide their employees with the necessary resources to improve their health and wellness. The NFPA also recommends that ergonomics training be done twice each year [1] to ensure that all employees are knowledgeable about how their body positioning can put them at risk for both acute and chronic injuries [6]. Ergonomics training could be employed as a form of active education through online interactive activities or through live, in person trainings facilitated by the fire department. Ergonomics was not widely discussed by fire chiefs through the instrument employed in this study, however, this could provide an opportunity for further education and training programs.

The WFI recommends that firefighters are alloc-ated 60 to 90 minutes per shift dedicated to imp-roving their physical fitness through exercise [4]. Therefore, departments must also have access to an adequate exercise facility whether that be within the department, through a contract with a local gym, or through access to other community resources like a park or fitness trail. However, only 19/54 (35%) res-pondents to our instrument reported having access to facilities and equipment to promote health and wellness. Fire chiefs and fire departments should continue exploring ways in which they can provide access to an adequate exercise area which could be done by using equipment already at fire stations for resistance training, using a community park or athletic complex to perform cardio, and body weight workouts, or consulting with a professional exercise instructor to develop a general program for the firefighters to use while on shift [4, 15].

The injury rate among firefighters has been identified to be twice as high as any other occupation [16]. We also know that sleep disturbances can increase the likelihood or rate of mental and behavioral health issues [17]. Therefore, firefighters are already at an increased risk for experiencing some form of mental or behavioral health concern without factoring in the stressors they experience from their job. Firefighters should be provided with training on how to handle difficult situations and where they can seek help whether that be with other coworkers or with medical professionals specializing in mental and behavioral health [17, 18]. According to the results from our study, fire chiefs have been working to improve access to these mental health resources and promoting the use of them.

4.2 Culture

According to the National Safety Culture Change Initiative, the most effective way to cause a change in culture within the fire service is by using a top down approach [8, 17]. A top down approach indicates that change starts with the fire chief of a department. The fire chief must believe in the efforts they are putting forth in order to alter the traditional mindset and culture of firefighters which can affect the “tough guy” mentality and stigma often associated with firefighters [8]. According to the data collected in our study, the stigma associated with injury and illness reporting and prevention is still present and therefore needs to be combated from the leadership of the organization. Fire chiefs should focus on demonstrating behaviors, promoting policy and expectations to effect a culture change within their department [8, 18].

Previous studies have evaluated the positive impact creating a supportive environment has on employee physical activity rates and likelihood of employees with mental health concerns to seek help [15, 18]. According to our study, fire chiefs understand the importance of creating a supportive culture or environment for their employees. Many of the fire chiefs that responded to our instrument reported that they were working to create a supportive and encouraging culture for their firefighters to promote injury and illness prevention and reporting.

4.3 Barriers

Literature has identified that some fire departments do not follow recommended or established standards primarily due to time and budget constraints or they do not understand the benefits of complying with them [19]. However, implementation of health and wellness programs in the past have resulted in approximately 28% fewer missed or lost work days caused by injury and illness [4]. Two primary reasons why health and wellness programs are ineffective include the firefighters are unwilling to make changes due to a lack of knowledge, and lack of appropriate training [20]. Our study confirms that a lack of knowledge is still perceived as a barrier to the reporting process, however, was not indicated as a barrier to improving health and wellness. Our study also identified that time may still be perceived as a barrier to promoting improved health and wellness; however, time was only reported as a barrier regarding paid time off for recuperative leave of part time firefighters. The present study identified budget may still be a barrier to health and wellness promotion, but the financial restrictions stem from workers compensation claim denials, or restricted coverage rather than with the fire department budget. The differences seen between our study and the barriers previously identified may be representative of the improvements made to the firefighter culture. Based on the present study, a cultural shift and improved support from fire chiefs has begun to create a more accepting environment which allows firefighters to feel more supported in reporting both physical injuries and mental illness.

Underutilization of current programs was reported by 7/54 (13%) fire chiefs that responded to our instrument classifying utilization as rare under the barrier domain. Utilization was not described in previous literature as a barrier to health and wellness promotion and does not seem to be a significant barrier based on the results of this study. Insufficient programming arose as a barrier in this study and was reported by 14/54 (26%) fire chiefs. Some fire chiefs that reported insufficient programming said that they had no programming or that the current programming was not satisfactory. Insufficient programming has been reported as a barrier to promoting health and wellness in previous literature associated with the fire service [3, 8]. Therefore, fire chiefs must continue working to improve programming efforts in order to promote improved health and wellness.

4.4 Limitations

This study was not without its limitations. The instrument received a relatively low response rate which can lead to less generalizable results. However, in comparison to previous qualitative studies, we did have a large sample population with a total of 54 participants. We believe the low response rate was due to limitations in recruiting the fire chiefs, whereas INFOCUS Marketing limited distribution of the instrument to a one-time e-mail without rem-inders. Another limitation is that fire chiefs that have implemented such interventions may have been more inclined to respond to the instrument compared to those fire chiefs that have not implemented any interventions. Future research should consider how to gather larger samples of fire chief and firefighters despite limitations in the current recruitment process. Future research should also use surveillance methods to track the effectiveness of the programs fire chiefs are already implementing.