BY JOHN J. McNEIL
“Do as I say, not as I do” repeatedly has been proven to be an ineffective leadership style for producing cultural changes within an organization. The prevalence of this type of leadership style as it pertains to firefighter health and fitness, I believe, is the crux of the problem when it comes to a lack of a substantial cultural change in health and fitness within today’s fire rescue service. According to the United States Fire Administration (USFA), there were 118 firefighter line-of-duty deaths (LODDs) in the United States in 2008. Stress or overexertion has consistently been the leading cause of firefighter line-of-duty deaths. Within the past five years, stress or overexertion accounted for 52 or 44.1 percent of the LODDs in 2008, 55 or 46 percent in 2007, 54 or 50.9 percent in 2006, 62 or 53.9 percent in 2005, and 66 or 56.4 percent in 2004.
In an effort to reduce LODDs, the major fire service organizations created numerous firefighter medical standards, investigative reports, publications, national conferences, national campaigns, and health and fitness programs. Since the terrorist attacks on the United States on September 11, 2001, millions of dollars of federal funding were used to establish health and fitness programs and purchase exercise equipment for firefighters across the United States to improve firefighter wellness and safety.
Despite these enormous efforts, the funding, and the resources applied toward the goal of reducing firefighter injuries and deaths, the U.S. fire service continues to experience unacceptable and preventable deaths and injuries each year. The problem is that organizations, standards, rhetoric, theories, plans, and funding do not result in successful cultural changes or endeavors. Endeavors are successful because people and leaders persuade others, through their behavior and example, to make changes. The USFA states that none of these efforts will be successful until we change the basic culture of firefighting to one that is less complacent about risk and does not accept that injuries and deaths “are part of the business.” This attitude is unacceptable.
THE PROBLEM
According to the USFA, stress or overexertion is a general category that includes firefighter deaths from heart attacks and strokes (cardiovascular accidents, or CVAs), and other events such as extreme climatic thermal exposure. Classifying a firefighter death in this category does not necessarily indicate that the death was a result of being in poor physical condition. Firefighting is extremely strenuous physical work and likely one of the most physically demanding activities a human body performs.
A study sponsored by the Federal Emergency Management Agency (FEMA) and conducted by St. Joseph’s Hospital in Atlanta, Georgia, studied first responders ages 40 and over who were at risk of sudden death or other significant cardiac events. Preliminary findings indicated that a third of the firefighters had heart disease unrelated to traditional risk factors, such as high cholesterol. Dr. Robert Superko, M.D., of St. Joseph’s Hospital, the principal investigator of this study of at-risk first responders, stated: “Those results are astounding and point at job duties and environment as the primary determinants for early death in our country’s first responders.”
According to Superko, job-related stress and psychological pressures, as well as diet and exercise issues and inherent personality, interacting with a genetic predisposition to heart disease, probably tremendously impact the risk of a heart attack in these first responders. The study concluded that firefighters have a 300-percent increased risk for cardiac disease as compared with other segments of the nation’s population.
THE SOLUTION
Two main groups should be considered when addressing the various causes of cardiac or cerebrovascular attacks in firefighters and initiatives for reducing LODDs in the United States. These groups are firefighter candidates or recruits (the recruiting and hiring process) and incumbent firefighters (their physical and medical maintenance).
Firefighter Candidates
Although it is obvious, it should nonetheless be stressed that recruits hired in a career fire department or accepted into a volunteer fire department will typically remain a member of the organization for many years. If fire recruits come into an organization with issues of obesity, lack of physical fitness for firefighting, or using tobacco products, the organization is obtaining a liability instead of an asset.
Researchers at the Boston University School of Medicine reviewed preplacement medical exams for 370 Boston-area firefighter and ambulance recruits between October 2004 and June 2007. The average age of the recruits was 26 years old. These researchers found that only 22 percent, or about one in five recruits, had a normal weight. Additionally, 44 percent of these recruits were overweight and 33 percent were obese based on the body mass indicator (BMI), a commonly accepted weight-to-height ratio.
It is critical for fire service organizations to implement physical and medical screening processes that can help them to avoid hiring potential liabilities. National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, lists the components of a comprehensive occupational medical program for fire departments and information for physicians and other health-care providers responsible for these programs.
The standard outlines an occupational medical program that, when implemented in a fire department, will reduce the risk and burden of fire service occupational morbidity and mortality while improving the health, and thus the safety and effectiveness, of firefighters operating to protect civilian life and property. Additionally, it states that implementing the medical recommendations outlined in this standard will help to ensure that firefighter candidates and current firefighters are medically capable of performing their duties and will help to reduce the risk of occupational injuries and illnesses.
The International Association of Fire Chiefs (IAFC) and the International Association of Fire Fighters (IAFF) collaboratively established a candidate physical ability test (CPAT), a physically challenging and firefighting-relevant physical ability screening that can be used to select physically capable firefighter candidates. This screening method will help to ensure that fire service organizations are hiring medically and physically fit applicants and may also lessen the probability of a fire service organization’s suffering a firefighter death caused by a cardiac or cerebrovascular attack.
Incumbent Firefighters
There is a need for initiatives that ensure the fire service organization is managing the medical, physical, and psychological well-being of its firefighters. Key elements include medical assessments, diet, exercise, the environment, and rest.
Health and fitness programs. NFPA 1583, Standard on Health-Related Fitness Programs for Fire Department Members, according to the NFPA technical committee, is to be viewed as a companion document to NFPA 1582 and a tool to be used in conjunction with the IAFC-IAFF Joint Labor-Management Wellness Initiative.
NFPA 1583 advocates that fire departments establish a health-related fitness program with components that include the assignment of a qualified health and fitness coordinator, a periodic fitness assessment for all members, an exercise training program that is available to all members, education and counseling regarding health promotion for all members, and a process for collecting and maintaining confidential health-related fitness program data.
The annual fitness assessment described in NFPA 1583 consists of components relative to aerobic capacity, body composition, flexibility, muscular strength, and muscular endurance. The exercise and fitness training program consists of an educational program that espouses the benefits of exercise, fitness, fitness training, and weight management; an individual exercise prescription; an aerobic exercise program; warm-up and cool-down exercise guidelines; a muscular, flexibility, and healthy back program; and a safety and injury prevention program.
Firehouse environment. Many fire departments face a number of concerns relative to the firehouse environment. They include the proper removal and elimination of diesel exhaust from fire apparatus inside the firehouse (the exhaust contains harmful carcinogens). Precautionary measures are needed to prevent the transfer of community-associated methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a strain of staph that’s resistant to the broad-spectrum antibiotics commonly used to treat it. The infection can spread among firefighters sharing facilities and equipment. Ergonomically correct office and living furnishings are needed, including bedding and chairs that help to prevent injuries to the lower back and neck because of poor posture. Alarm systems should be modified so that they alert firefighters but do not have sounding modes that are so loud that they present the risk of hearing loss or add to firefighters’ stress.
Fatigue management. The IAFC and the USFA, with the assistance of the faculty of the Oregon Health and Science University, examined the issue of sleep deprivation as it pertains to firefighters and EMS responders. The results were published in June 2007 in Effect of Sleep Deprivation on Fire Fighters and EMS Responders. One of the study’s objectives was to assist fire service leaders in minimizing duty-related sleep deprivation. The study included a critical analysis by the National Institute for Occupational Safety and Health (NIOSH) (commissioned in 2004) of the impact of chronic sleep deprivation and long work hours (shifts lasting longer than 10 to 18 hours). The findings indicated that sleep deprivation and long hours reduced the ability to think clearly and handle complex tasks; caused depression, stress, and irritability; and were associated with health complaints, obesity, obstructive sleep apnea, and possibly a heightened risk for cardiovascular disease.
In many career fire departments, a work shift cycle of 24 hours on duty is followed by 48 hours off duty. Many firefighters find this schedule attractive; it enhances morale and job satisfaction because firefighters spend less time commuting to work and it facilitates working a second job or pursuing hobbies and other interests. Work schedules with extended hours necessitate fatigue management both on and off duty. On duty, there must be balance with more breaks and a slower pace. Off duty, there has to be an awareness of and commitment toward managing fatigue and restorative sleep.
The study also revealed that newer markers of inflammation relating to cardiovascular risk have been linked to sleep deprivation. The health profile of most firefighters and EMS responders is similar to that of a majority of adult Americans: Less than 10 percent eat a healthful diet, exercise regularly, and have optimal body weights. The recommendation for six to eight hours of sleep a night decreases even more the percentage of people achieving optimal health objectives.
A comprehensive approach to managing fatigue and gaining restorative sleep is necessary to prevent the dangers of chronic sleep loss and maintain firefighters’ psychological, physical, and medical well-being. According to the study, effective fatigue-management programs should have the following key components: organizational commitment, an explicit fatigue management policy and process, involvement of stakeholders at all levels, subjective (opinions and beliefs) and objective measures of the programmatic outcomes, and ongoing monitoring and improvement.
Specifically, organizational leaders must be open to a cultural change that considers this aspect of the firefighter’s well-being. Understanding the need for a slower pace on duty—allowing scheduled power naps (45 minutes or less) for restorative sleep—and providing sleep accommodations conducive to restorative sleep during day or evening hours are cultural changes needed to address firefighter health and safety and reduce the potential risk of cardiovascular or cerebrovascular attacks caused by accumulative sleep deprivation and related stress.
Additionally, firefighters must also be open to a cultural change that commits to a healthful lifestyle: daily physical activity, a healthful diet, maintaining a healthful body weight, not smoking, and acquiring restorative sleep while off duty.
CULTURAL CHANGE STRATEGIES
The leadership. According to Robert Greenleaf, author of Servant Leadership: A Journey into the Nature of Legitimate Power & Greatness (Paulist Press, 2002), the causes of failing to effect change include an unrealistic time frame for capacity building, change driven solely by compliance, and change that is not modeled by the leadership.
Realistic capacity building. Greenleaf espouses that innovative organizations take a capacity building approach in their change strategy. This includes setting as a goal the implementation of the change initiatives and determining what needs to be done to achieve success. Without attaining significant organizational readiness and support from the leadership on all organization levels, success will be difficult to achieve. Lack of cooperation, poor communication, and lack of support of lower management will stifle the change process.
Leaders must truly want to reduce the number of firefighter fatalities caused by cerebrovascular attacks; be ready for a cultural change; and then make the organization, beginning from the top and working down through the various ranks and levels, aware of their dissatisfaction with the status quo regarding LODDs. One technique leaders can use is to identify a fire company, a battalion of fire companies, or a department section in which they believe implementation would most likely succeed. These units would already be close to the new model, exhibiting a high level of cooperation and leadership that has already produced a positive working environment. Leadership would make available to these designated companies the amenities and resources needed to implement the change initiatives: exercise equipment, structured rest and exercise periods, health and fitness education, medical and physical assessments, and new furnishings that prevent potential neck and back injuries. Additionally, they could offer some individual incentives or benefits such as exercise outfits, program T-shirts, and recognition/incentives for successfully attaining personal health and fitness goals.
Selecting these units as pilots or models will have an impact on the nondesignated companies. Fire officers in the other companies will also want to participate in the process and gain the benefits given to the model companies. The “dissatisfaction competition” will produce a readiness for change in these other fire companies.
Educating firefighters on the medical and physical dangers of their job and how lack of exercise, unhealthful diet, sleep deprivation, and environmental stress contribute to their risk can help to create organizational readiness for cultural change. The education process should be comprehensive and include family and other members of the firefighters’ support system, such as labor and fraternal organizations. The collaborative efforts to educate firefighters, their peers, their family, and their support system, in conjunction with a cooperative effort to reach the best methods for implementing more healthful lifestyle changes (on and off duty), will be much more effective than a top-down regulatory approach. According to Heifetz and Linsky, coauthors of Leadership on the Line, (Harvard Business School Publishing, 2002), “To meet adaptive challenges, people must change their hearts as well as their behaviors. Solutions are achieved when the people with the problem go through a process together to become the people with the solution.” This approach enhances the capacity of the organization to change through realizing the need for changes and becoming inspired to make those changes.
ASPIRATION
Cultural change is a long march wherein goals are established and readiness is required at all levels, and aspiration—rather than regulation or mandates—drives the change usually within an unrealistic time frame. Aspiration drives most successful changes because it is more meaningful or represents a greater cause or something we care deeply about. Greenleaf explains the difference between compliance and aspiration as “doing what we’re here to do versus doing what someone said we ought to do.”
According to Heifetz and Linsky, leaders who approach adaptive changes with technical fixes that strictly use rules and regulations will not achieve success. Changes that are adaptive in nature require people’s hearts and minds. Dictating a change in lifestyle from the top down through rules and regulations inside the department will, at best, achieve minimal compliance.
Leadership Commitment and Modeling
Ultimately, the organization’s leadership must provide a depth of commitment that embraces the necessary cultural changes previously discussed. The leadership must break away from previous beliefs and inconsideration regarding work pace, restorative sleep or naps, work environment, diet, and exercise. Adaptive change requires leaders to take responsibility for their piece of the mess and their lack of modeling the desired behavior. When organization leaders are implementing adaptive change, they have to recognize their part in the existing problem or their contribution to helping to effect the needed change.
Besides acknowledging their role in the problem, leaders must model the behaviors and changes they are asking others to commit to, or there will be no credibility regarding the adaptive change. The modeling of behavior that promotes great health and fitness is a significant challenge for many leaders in the fire-rescue service, because they, themselves, are products of the same culture that is undergoing change. Many of these leaders are overweight, have poor diets, lack exercise, and work long hours. Nonetheless, the change initiatives have a chance for success only if the organization’s leadership models the desired behaviors and suffers through the changes with everyone else in the organization. Leaders’ words that are not followed by their example will be meaningless and doom the cultural change to failure.
Sustainability
If these change initiatives are to become truly integrated into the culture of the fire-rescue service, there is a need to create a new spin-off team within the structure of the organization to sustain the change process. The creation of an organizational team or office focused solely on firefighter health and safety is critical to sustaining the change process. The creation of this new capability within the organization helps to ensure that the initiatives continue to evolve, improve, and gradually become fully integrated into the organization’s culture. NFPA 1583 states that fire departments, under the direction of the chief, shall appoint a health and fitness coordinator to administer, maintain, and sustain the components of the health and fitness change initiatives. Failure to maintain the course and hold steady the process of adaptive change can cause the initiatives to be lost instantly. Without ongoing focus on these important health and fitness initiatives, most likely the changes will merely be a flash in the pan or just more initiatives lost in the distraction of other numerous projects and priorities and then soon forgotten.
Firefighting, rescue, and other types of emergency operations are essential activities in an inherently dangerous profession, and unfortunate tragedies do occur. This is the risk all firefighters accept every time they respond to an emergency incident. However, the risk can be greatly reduced if organization leadership will implement these health and fitness initiatives and apply the essential components of adaptive change. The challenge is to make use of these essential components of cultural change and move the fire service closer to the tipping point whereby firefighter health and wellness are revered, accepted, internalized, and practiced regularly.
JOHN J. McNEIL is the director of emergency services for Rockdale County, Georgia. He retired as deputy chief from the Atlanta (GA) Fire Rescue Department, where he served for 27 years. During his tenure, he served as deputy chief of technical services, assistant chief of training, and battalion chief; he has 20 years of experience in field operations.
