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A New Model for Optimizing Firefighter Human Performance

Romero, Manny MS, CSCS, TSAC-F 1 ; Alvar, Brent PhD, CSCS*D, TSAC-F, FNSCA 2

1 Navy Fitness, Commander, Navy Installations Command, San Diego, California; and

2 Department of Kinesiology, Point Loma Nazarene University, San Diego, California

Address correspondence to Manny Romero, [email protected] .

Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding.

Firefighting is a profession that has the potential to be extremely demanding, both physically and mentally. More specifically, these tactical personnel must be physically fit to perform their occupational requirements, all while they are exposed to daily stressors. This is likely to include everything from physical strain and shift work to interrupted sleep and witnessing potentially traumatizing events. Failure to prepare and mitigate these occupational demands can have long-lasting implications to overall performance as well as health and wellness. Unfortunately, many of these elements often go unaddressed. As such, considerations for collaborative and overarching cross-disciplinary allied health teams should be made. Human performance optimization (HPO) is a model that has been successfully adopted by the U.S. military to enhance the overarching health, wellness, and performance of soldiers. This article proposes the utilization of a similar HPO model by providing a rationale for how it can be used to reduce premature morbidity and mortality, as well as increasing overall readiness and resilience within the firefighting profession.

INTRODUCTION

In 2006, human performance optimization (HPO) and Total Force Fitness (TFF) emerged as conceptual frameworks within the Department of Defense (DoD) ( 19 ). The objectives of these frameworks are to provide a holistic approach for enhancing the performance, health, and well-being of U.S. soldiers and their families ( 19 ). Today, these frameworks are ingrained throughout the DoD and are indispensable to the military community ( 19 ). With the successful integration of HPO and TFF in the military community, the time has come to discuss the use of similar concepts that are best suited for members of public safety (i.e., firefighters and law enforcement). The purpose of this article is to discuss the possible use of an adapted HPO model for optimizing human performance within the fire service.

Firefighting is a physically demanding occupation; therefore, having good physical conditioning is paramount for improving occupational performance and preventing musculoskeletal injuries ( 3,4,9,18,28–30,35,58,65,66,68–70,75,81 ). Equally important are the components of health and wellness, which have been shown to influence a firefighter's ability to perform their duties and may impact their health and well-being ( 10,13,14,17,24,31,32,35,42,46,58,68,70,71,74,76,78,82 ). Nationally, fire departments are well aware of the physical and occupational health risks of the job because the number of department-operated health and wellness programs continues to increase ( 1,41,60 ). In relation to firefighters, HPO may be conceptualized as the junction of health, wellness, and performance, where knowledge, skills, and technology are used in a patient-centered approach to enhance and/or preserve an individual's job performance, career longevity, and overall well-being. As seen in Figure 1 , the approach to HPO would integrate all 3 domains in a synergistic manner and potentially bridge the gap between the need for firefighter health, wellness, and performance interventions and achieving sustained improvements in firefighter health, wellness, and performance outcomes. It is possible that current programs, although well intended, provide interventions that only partially address the components of HPO. Consequently, HPO should be the primary goal of any health and wellness program that focuses on firefighter health, wellness, and fitness.

Current and future firefighter health and wellness programs can specifically address all areas of HPO by using the firefighter health and wellness model (FFHWM) seen in Figure 2 , along with the integration of an interdisciplinary team of professionals ( Table 1 ). To the authors' knowledge, this is the first model in the scientific literature that demonstrates the comprehensive relationship of each domain for firefighter HPO. Existing and future firefighter health and wellness programs could use the overarching FFHWM to ensure all areas are considered and to prevent the creation of silos between professionals. Program directors and key decision makers must view firefighter health and wellness as umbrella constructs that can be divided into various measurable components, including physical, mental, emotional, and environmental. Moreover, each of these can be subdivided into smaller areas of focus. For example, the physical component embodies health concerns, job performance needs, and injury prevention/rehabilitation in relation to fire-rescue personnel. The mental component includes, but is not limited to, sleep quality, psychosocial behavior, emotional intelligence, and self-awareness. The emotional component encompasses stress management, coping mechanisms, self-esteem and self-efficacy, and resilience. Finally, the environmental component relates to firefighter culture/social ethos, social support systems, and interpersonal relationships. Examples from select individual components of the FFHWM will be discussed in the subsequent sections. Before discussing each component, it is important to highlight the need for an interdisciplinary team of professionals to oversee each component of the FFHWM, as some interventions may fall outside the scope of practice for certain professionals.

USING AN INTERDISCIPLINARY TEAM TO INTEGRATE THE FIREFIGHTER HEALTH AND WELLNESS MODEL

Health, wellness, and performance professionals often operate in silos. However, under the concept of firefighter HPO, it would be ideal to merge all 3 domains because of their interrelationship. A crossover exists between each domain, allowing each profession to supplement their knowledge, skills, and abilities with the others. For example, Certified Health and Wellness Coaches (HWCs) may also have the proper credentials to act as an exercise physiologist and/or the Certified Strength and Conditioning Specialist (CSCS). A second example can be seen with the registered dietitian (RD), as this individual would provide nutritional expertise in all 3 domains depending on the goal of the individual firefighter. A third example would involve a collaboration between performance professionals, medical staff, and wellness professionals to assist the return-to-duty process for a firefighter recovering from a severe injury. Therefore, an interdisciplinary team of qualified professionals is essential for providing the appropriate guidance and expertise needed for a successful integration of the FFHWM and for achieving firefighter HPO.

Each professional can be categorized by the domains of the HPO model, which can be reviewed in Table 1 . To represent their interrelationship and simplify the understanding of their job assignments, these professionals may also be referred to as medical providers and human performance staff. A team of medical providers would include physical therapists (PTs), athletic trainers (ATs), RDs, physicians, a registered nurse (RN), and a physician assistant (PA). Whereas the human performance staff would include CSCSs, Tactical Strength and Conditioning Facilitators (TSAC-Fs), HWCs, exercise physiologists, psychologists, and occupational therapists (OTs). The key benefit of having an interdisciplinary team of professionals would be the disruption of current silos by merging all professions under one roof. This will likely improve the sharing of knowledge and expertise to collectively work toward a common goal: optimizing the firefighter performance capacity, career longevity, and quality of life. A second benefit is to ensure that each area of HPO and the FFHWM can be appropriately addressed by a credentialed professional who is trusted by his or her respective fire department. To better understand the need for each profession and the need for the FFHWM, a review of health-related, wellness-related, and performance-related literature will be discussed.

THE NEED FOR HUMAN PERFORMANCE OPTIMIZATION IN THE FIRE SERVICE: A BRIEF REVIEW OF THE LITERATURE

The most notable firefighter health concerns include cancer, sudden cardiac arrest (SCA), cardiovascular disease (CVD), pulmonary function, pulmonary artery disease (PAD), obesity, hypertension, and diabetes ( 16,20,25–27,35,40,49,56,58,68,74 ). The International Association of Fire Fighters (IAFF) reported that 120 firefighters died of cancer in 2018 ( 26 ). There is evidence that suggests occupational exposure to carcinogens and other toxicants are likely contributors to cancer risk ( 40,56 ). What is more, heart attacks have been the leading cause of death in the fire service for over 2 decades ( 25,26,68 ). Stress and overexertion are the main risk factors that are correlated with fatal and nonfatal cardiac events in firefighters ( 25,26,68,82 ). Most recently, 60 and 64 deaths were reported in 2017 and 2018, respectively. In 2018, SCA accounted for 11 (44%) and 13 (38%) deaths in career and volunteer firefighters, respectively ( 26 ). According to Soteriades et al. ( 74 ), on-duty CVD events and early retirements related to heart disease occur almost exclusively among firefighters with the underlying CVD risk factors. These risk factors include smoking, hypertension, obesity, coronary heart disease, dyslipidemia, and diabetes. Additionally, Soteriades et al. ( 74 ) reported an estimated 45% of about 100 on-duty deaths per year are related to CVD. The number of all on-duty firefighter deaths has steadily declined between 1977 and 2018 ( 25–27 ). Although promising, health issues such as cancer, SCA, and CVD are still major concerns for the fire service and must be addressed through appropriate interventions.

Personal choices such as diet, exercise, and well-being are all variables that fire departments can provide education as well as professional guidance ( 58 ). There is evidence that shows the use of good nutritional practices and regular participation in physical activity and exercise can improve the health status for firefighters ( 5,34,58,74 ). Although there are several holistic approaches that can be used to improve firefighters' health status, it is beyond the purpose of this section to comprehensively examine each approach. Instead, the focus will remain on nutrition and physical activity/exercise because they are likely to make a substantial and sustainable impact on firefighters' health outcomes. Furthermore, the following will help justify the inclusion of an interdisciplinary team of professionals to oversee HPO interventions.

Firefighters who practice good nutrition habits can simultaneously improve health, wellness, and performance parameters ( 6,34,58,72–74 ). Having the appropriate professional guidance is vital, as many complex nutrition topics fall outside the scope of practice for most professionals ( 34,72 ). This is especially true when an individual firefighter has been diagnosed with a medical condition (i.e., type 1 or 2 diabetes, hypertension, and food allergies). RDs are experts on food and nutritional sciences who can oversee individualized and/or department-wide nutrition programs and interventions ( 34,63 ). Furthermore, RDs are able to provide evidence-based guidelines that promote proper food choices, as well as behavioral and dietary counseling ( 34,63 ). Unique to RDs is that they are able to be involved in all 3 domains of the HPO model. There is evidence that supports supplementing well-balanced food choices with physical activity and routine exercise is likely to provide additional benefits ( 5,9,58,74 ). The American College of Sports Medicine ( 5 ) defines physical activity as any bodily movement produced by the contraction of skeletal muscles (i.e., walking, household and occupational tasks, and sports). Whereas exercise is defined as a planned, structured, and repetitive form of physical activity performed to improve/maintain several components of physical fitness (i.e., muscular strength, muscular endurance, flexibility, balance, agility, and speed). There is extensive evidence that supports the inverse relationship between physical activity and/or exercise and several health outcomes ( 5,9,74 ). Therefore, supplementing routine physical activity with exercise programs is paramount for improving the firefighter's health profiles and mitigating common occupational health concerns ( 5,9 ). HWCs, CSCSs, TSAC-Fs, and exercise physiologists are ideal professionals who should be tasked with overseeing the promotion of physical activity, designing of individual exercise programs, and guiding firefighters toward achieving their specific fitness-related and performance-related goals. Furthermore, these professionals would collaborate with physicians, PAs, RNs, and RDs when assisting firefighters who have been diagnosed with a medical condition (i.e., diabetes and hypertension). Considering the health concerns seen within the fire service, the time has come for fire departments to place a higher priority on developing good nutrition and physical activity/exercise habits. This should be performed with the oversight and collaboration of a team of interdisciplinary professionals. Equally important to improving health-related outcomes is an emphasis on well-being topics, which will be discussed in the next section.

Some of the most prominent wellness concerns in the fire service include sleep deprivation, a disrupted circadian rhythm, coping mechanisms, suicide, and occupational resiliency ( 10,25,26,35,51,58,68,74,76,78,82 ). Orr and Bennett ( 58 ) have documented key risk factors requiring intervention; these include physical inactivity, occupational stress, tobacco use, excessive alcohol consumption, sleep disruption, and nutritional habits. It is important to note that the presence of multiple risk factors is likely to have a compounding effect. Consequently, interventions such as health and wellness coaching, smokeless tobacco cessation, substance abuse, and stress management workshops, nutritional guidance/counseling, occupational therapy, and psychosocial treatments should be included in an overarching health and wellness program to supplement health and performance interventions. Wellness topics are likely to fall outside the scope of practice for some health and performance professionals. Therefore, firefighter health and wellness programs should consider the inclusion of a well-rounded team of qualified wellness professionals ( Table 1 ) to facilitate appropriate wellness interventions and mitigate key risk factors. The following will discuss firefighter sleep, coping mechanisms and resiliency, and culture/social ethos because these areas are the more prominent wellness concerns from the FFHWM that may greatly affect job performance, career longevity, and overall well-being ( 10,35,51,58,68,74 ).

SLEEP—MENTAL COMPONENT OF THE FIREFIGHTER HEALTH AND WELLNESS MODEL

Substandard sleep hygiene can reduce attention, concentration, reaction time, memory, and the ability to make quick decisions; fatigue, higher stress levels, loss of humor, and probability of ill tempers are also affected ( 35,46,51,76 ). Lim et al. ( 50 ) sought to analyze various factors that may affect firefighters' sleep quality. The factors analyzed were categorized as sociodemographic, psychosocial, and occupational. Sociodemographic characteristics include age, marital status, alcohol intake, smoking, body mass index, and exercise. Psychosocial characteristics include sleep quality, depression, and psychosocial health. Occupational characteristics include years of service, shift work, departmental affiliation, and musculoskeletal symptoms. In relation to these factors, multiple studies have found that sleep quality is significantly related to shift work, depression, and musculoskeletal pain ( 2,11,35,50 ). In addition, a significant number of firefighters have reported having a second job, which may adversely affect sleep quality as well ( 11 ). These decrements are undesirable when seeking to optimize firefighter human performance. Therefore, strategies for improving sleep quality should primarily address the factors mentioned above. A few holistic interventions that may be beneficial include a change to shift work (24 on/48 off shift schedule), the integration of mental health professions, and the management of musculoskeletal injuries.

It might also be beneficial to discuss potentially revising shift work schedules, knowing this will not provide a universal solution. With that stated, fire departments should consider the use of an alternative work shift schedule to help decrease circadian dysrhythmia and promote proper recovery. The 24 on/48 off (ABC) is one of the more commonly used work shift schedules that could potentially be revised. In this scenario, 3 firefighter crews are needed: A, B, and C. One crew would man the fire station for 24 hours until they are replaced by the subsequent crew and given 48 hours off from the work. It is important to note that the amount of shift work hours can dramatically increase when responding to catastrophic emergency calls. Moreover, each fire department has different and unique needs. Depending on the call volume during the 24-hour shift, the individual members of a firefighter crew may have trouble unwinding and recovering during their 48 hours off. During this time, the individual firefighters may be catching up on lost sleep from the previous shift, fulfilling family duties and personal responsibilities, and preparing for the next 24-hour shift. In this case, 48 hours off may not be sufficient for allowing time to recover physically and mentally. It is possible that a 48 on/96 off schedule may be a reasonable alternative. In this scenario, the individual members of the crew would have 2 days of shift work, followed by 4 days off to recover physically and mentally. However, fire stations who receive a higher-than-normal call volume may not find the 48 on/96 off schedule as a reasonable solution. By contrast, fire stations with lower-than-normal call volumes may find the 24 on/48 off shift schedule to be more appropriate. Ultimately, the decision to change shift work schedules should be made by key decision makers of the respective fire department and must consider these variables to better optimize firefighter sleep and recovery. Although changes in shift work would likely benefit an individual's sleep quality, the occupational stressors of firefighting are considered risk factors that may lead to depression among firefighters ( 50 ). Therefore, changes to shift work must be accompanied with strategies to identify depression and professional oversight to clinically treat depression symptoms.

Previous research has shown that firefighters are at an elevated risk of developing sleep disorders and depression ( 2,14,37,50 ). Moreover, depressed firefighters are more likely to be sleep deprived and/or experience insomnia. However, the National Sleep Foundation ( 57 ) suggests that there is mutual causality. Adults with insomnia (or other sleep disorders) are likely to develop depression, whereas depressed individuals may develop insomnia symptoms. This creates a challenging scenario for the fire service because it may be difficult to identify the root cause for depression. Nonetheless, depression can be diagnosed and monitored with appropriate evaluations, therapy interventions, and psychosocial counseling. Without a doubt, these duties fall outside the scope of practice for professionals such as PTs, ATs, physicians, HWCs, CSCSs, and TSAC-Fs. Therefore, integrating a psychologist who specializes in psychosocial therapy and an OT into a firefighter health and wellness program may help firefighters who are struggling with depression improve their sleep quality or vice versa. Psychologists often work with individuals who struggle with short-term problems (i.e., stress from a new job) and chronic conditions (i.e., bipolar disorder) ( 8 ). Furthermore, they can guide others toward learning how to cope with stressful situations, overcome addictions, and break past barriers that prevent them from achieving their goals ( 8 ). In addition to the psychologist, the American Occupational Therapy Association ( 7 ) has defined the role of an OT as a professional who helps individuals of all ages participate in the things they want and need to do using everyday activities ( 7 ). What is more, OTs help individuals function in each of their environments (i.e., home, work, school, and community) and address the physical, psychological, and cognitive aspects of their well-being through engagement of occupation ( 7 ). The individual firefighter is ultimately responsible for disclosing their struggles with fire department leadership and must seek out help from the psychologist and/or OT. Although this might seem like a simple step to take, firefighters' culture and social ethos may prevent this from taking place; this will be discussed shortly. Furthermore, professionals under the performance and health domains from Table 1 must be aware of the signs and symptoms for depression—among other mental disorders—and report these observations to fire department leadership and the psychologist and/or OT.

As mentioned previously, musculoskeletal pain may impact a firefighter's ability to sleep. Moreover, musculoskeletal pain/disorders may contribute to the development of depression ( 50 ). Therefore, a team of sports medicine professionals (PTs and ATs) should be used to mitigate musculoskeletal pain and manage occupational injuries ( 52,63 ). A sports medicine team and strength and conditioning staff (CSCSs and TSAC-Fs) may provide additional benefits such as injury prevention, when administering physical training interventions for fire academy recruits and career firefighters. If time constraints are a limitation, PTs, ATs, CSCSs, and TSAC-Fs can integrate personalized corrective exercises into a routine warm-up protocol to be completed before a physical training session. The regular use of corrective exercises and other preventive interventions, as prescribed by PTs, ATs, CSCSs, and TSAC-Fs, would help mitigate musculoskeletal pain and reduce injury risk ( 52,63 ). Consequently, a proactive approach to musculoskeletal pain could potentially help firefighters improve their sleep quality and quantity.

COPING AND RESILIENCE—EMOTIONAL COMPONENT OF THE FIREFIGHTER HEALTH AND WELLNESS MODEL

Coping mechanisms is another area that would benefit from holistic interventions. Traumatic events experienced by firefighters have the potential to develop posttraumatic stress disorder (PTSD), which is often accompanied by depression, suicide, anxiety, substance abuse, and tobacco and alcohol use ( 32,33,39,42,62,71 ). Moreover, PTSD can cause symptoms of fatigue, impaired concentration, loss of interest in activities, disrupted sleep, irritability, social atrophy, vigilance, and behavioral avoidance, all of which can cause problems in efficiency and social relations in the workplace and with loved ones ( 23,42 ). Most firefighters have memories of traumatic events from their occupational duties. These memories include but are not limited to treating fatalities/injured patients, threat/injury to self, and death/injury to fellow firefighters ( 42 ). Concomitantly, the likelihood of threat, death, and injury to oneself and/or colleagues are traumatic events connected to mental health and PTSD, as well as physical, psychosocial, and environmental work limitations ( 42 ). It is common for firefighters to believe they are immune to the cumulative stress of trauma, but this could potentially lead to symptoms of PTSD, emotional exhaustion, and work limitations ( 31,33,42 ). Firefighter culture has also generated perceived barriers for disclosing traumatic experiences, which will be discussed in the subsequent section ( 31,38,78 ). Given the risk for PTSD, suicide, depression, anxiety, substance abuse, and tobacco and alcohol use in the fire service, it would be logical to consider proactive interventions for reducing the probability of these wellness concerns. One example would be the development of resilience and coping mechanisms during fire academy training as the individual fire recruit has yet to experience traumatic emergency calls that are not simulated in a safe environment. This approach could potentially reduce the severity of traumatic experiences early in a firefighter's career, while simultaneously establishing a rapport with a trusted professional before additional coping interventions may be needed. It is important to note that strategies and interventions required to develop resilience are likely to fall outside the scope of practice for most performance and health professionals. Therefore, these interventions should be administered by a clinically trained psychologist and supported by an interdisciplinary team and the respective fire department. These efforts are likely to establish an environment for prioritizing wellness concerns. To assist with this process, a discussion on firefighter culture/social ethos must take place.

CULTURAL/SOCIAL ETHOS—ENVIRONMENTAL COMPONENT OF THE FIREFIGHTER HEALTH AND WELLNESS MODEL

Through academy training, responding to emergency calls, and shared time on-duty, firefighters develop a close bond with one another, which can also be described as a “family” atmosphere ( 31,33 ). Every fire department has a set of rules and behaviors that collectively create a social environment. It is no secret that the social ethos of the fire service encourages aggressive behaviors to overcome challenges and occupational obstacles ( 10,31,33 ). Banes ( 10 ) suggests that these characteristics and risk-taking behavior are in place because of the psychological need to appear competent. Firefighters willingly admitting that a particular emergency call is bothering them can be perceived as a sign of weakness and/or incompetence ( 10,31,33 ). Experiencing traumatic events is a common occurrence for those who work in the fire service ( 31 ). However, it is not common for human beings to witness these events on a regular basis; therefore, processing these experiences may potentially be vexatious and/or bothersome. What is more, it is also uncommon for firefighters (or anyone for that matter) to know how to appraise and process these traumatic experiences. Some members of the fire service may be good dealing with a wide variety of critical incidents, but the possibility of overlooking the aftermath from traumatic events is still present ( 31,33 ). In fact, there are a number of perceived barriers in reporting mental and behavioral concerns within the fire service. Researchers ( 38,78 ) have reported embarrassment, career jeopardy, lack of department resources, unhelpful services provided, difficulty reporting a worker's compensation claim, and the idea of letting fellow firefighters down as the most challenging barriers that prohibit accurate reporting of mental and behavioral concerns. This has led to firefighters having difficulty asking for help both on-the-line-of-duty and off-the-line-of-duty. Banes ( 10 ) argues that these types of cultural norms could prevent firefighters with CVD risk factors or subclinical disease from withdrawing from intense fire suppression or physical work, even if cardiovascular symptoms such as chest pain develop. This is a concerning issue as an early warning sign for a fatal event would be ignored. Therefore, it is imperative that fire department officials collaborate with an interdisciplinary team of professionals to establish a culture where firefighters accept that some events and/or emergency calls will be troublesome and difficult to cope with. Firefighters must believe that expressing and sharing their posttraumatic concerns with fire department leadership and qualified professionals is a sign of strength and part of their personal and departmental HPO. A universal message must be sent that those who choose to say nothing could potentially place themselves and/or other firefighters at risk.

PERFORMANCE

Although firefighter fitness programs and wellness initiatives are currently in place, there is little to no evidence that strength and conditioning interventions have been fully integrated and accepted into a routine physical training schedule. Unique to this population is that these individuals are not exposed to the same demands and training schedules that a conventional athlete would experience. Moreover, their occupational tasks and shift schedules are often more demanding than the average American worker. It is important to note that there are distinct differences between training for fitness versus strength and conditioning. The former typically focuses on basic levels of muscular fitness (strength and endurance), aerobic training, and aesthetics (body composition), whereas the latter uses an evidence-based practice to address key areas for performance enhancement (i.e., strength and power development, speed and agility, and energy systems development) and injury prevention techniques.

Several studies have shown that the physiological, biomechanical, and occupational demands of firefighting, along with extreme environmental exposures, all combine to affect job performance ( 4,9,18,29,30,48,53,59,65,66,68–70,81 ). Rhea et al. ( 65 ) found that firefighter job performance was significantly correlated with muscular strength, local muscular endurance, and anaerobic endurance. High levels of grip strength are needed for tasks such as opening fire hydrants, pulling hoses, and load carriage ( 35,65 ). In addition, previous studies have demonstrated the importance of cardiovascular endurance when completing occupational tasks ( 17,22,35,68 ). Therefore, it is imperative that firefighters participate in strength and conditioning programs, as well as overarching health and wellness programs, to optimize human performance. A brief review of biomechanical, bioenergetics, and musculoskeletal injury analyses will be summarized to comprehensively understand the need for professionals such as PTs, ATs, CSCSs, TSAC-Fs, and exercise physiologists.

BIOMECHANICAL ANALYSIS

Firefighters are required to complete various tasks in diverse environments, such as communities, residential areas, woodlands and forests, government property, grasslands, and military bases ( 68 ). Firefighting tasks encompass the activities of rescue, fire suppression, operating various hand tools, and property conservation in buildings or other structures ( 68 ). Almost all firefighter tasks can be categorized as multijoint movements, suggesting that multiple muscle groups and muscular contractions (i.e., eccentric, concentric, and isometric) are used. These tasks include, but are not limited to, load carriage up and down a flight of stairs, movement with personal protective equipment (PPE), operating a hose line, half-kneeling and upright hose pulls, crawling, ladder raising, performing a forcible entry, victim dragging, operating various hand tools, chainsawing while under load, and stair climbing ( 3,4,35,68,70 ). Many physically demanding tasks occur in the sagittal plane, while using major muscle groups and multiple joints ( 3,68 ). However, movements in the frontal and transverse plane are also included in the occupational tasks of firefighters ( 3,68 ). A thorough representation on the biomechanical analysis of firefighter tasks has been documented by Abel et al. ( 3 ), Abel et al. ( 4 ), and Sell et al. ( 68 ), which can be seen in Table 2 . These analyses show that the commonly used muscle groups include the core, legs, back, and shoulders. Consequently, CSCSs, TSAC-Fs, and exercise physiologists must emphasize these muscle groups when designing physical training programs. Although adequate levels of strength and endurance should be developed with these muscle groups, care must be taken to prevent overtraining so that occupational readiness is not compromised.

ENERGY SYSTEMS (BIOENERGETICS) ANALYSIS

There is evidence that suggests decrements in firefighter job performance are related to the function of both anaerobic and aerobic energy systems ( 3,4,18,35,53,61,65,67–70,79,81 ). Depending on the severity of an emergency call, the duration of firefighter occupational tasks could last hours, days, or weeks. Moreover, the duration of immediate tasks such as stair climbing, victim dragging, load carriage, and forcible entry can range from a few seconds to several minutes. The cardiorespiratory demands of firefighting are well documented, showing oxygen uptake levels of 63–97% of maximum and heart rate values of 84–100% of maximum ( 68 ). An aerobic capacity of at least 42 mL·kg −1 ·min −1 or 12 METs has been recommended to meet the demands of most firefighter tasks ( 17,21,22,35,68 ). These findings suggest that firefighter tasks expend all 3 energy systems: phosphagen (ATP-CP), glycolytic, and oxidative. The intensity and duration of an occupational task often dictates which energy system is used primarily. Abel et al. ( 3 ), Abel et al. ( 4 ), and Sell et al. ( 68 ) have documented a physiological assessment of typical fireground tasks that classifies the energy system primarily used ( Table 3 ). Firefighter strength and conditioning programs must improve these energy systems through appropriate training interventions administered by CSCSs, TSAC-Fs, and exercise physiologists.

MUSCULOSKELETAL INJURY ANALYSIS

In 2018, the National Fire Protection Association (NFPA) reported an estimated 58,250 firefighter injuries, which is approximately 600 fewer than the 2017 report ( 13,24 ). Strains, sprains, and muscular pain accounted for 38% of the major types of injuries and were the most reported nature of injury based on the type of duty ( 13 ). It is important to note that musculoskeletal injuries in firefighter populations are not isolated to one area of the body. In fact, the most common sites for sprains and strains were the lower extremity, followed by the trunk, shoulder, and neck ( 12,68 ). The lower back, knee, ankle, hand and fingers, neck, and shoulder are some of the most reported body parts injured when completing firefighter tasks ( 12 ). In 2016, the NFPA reported that handling charged hose lines, suppression support, overhaul, and unspecified extinguishing fire/neutralizing incidents are the tasks that have contributed most to fireground injuries ( 12 ). Furthermore, it is possible that firefighters are also susceptible to muscular imbalances as a result from unilateral occupational tasks that favor the individuals' dominant side (right or left) ( 68 ). Overexertion or strain (28%) was the leading cause of firefighter injuries ( 13 ). A key factor that influences overexertion could be attributed to load carriage. Load carriage has shown to increase physical strain and heart rate while standing in physically active men ( 36,66 ). The most common type of load a firefighter is exposed to is their PPE and a self-contained breathing apparatus (SCBA). PPE and SCBA are essential for protecting the firefighters from physical and chemical harm but could potentially affect efficient movement patterns as stability, joint range of motion, and balance can be influenced by the additional load ( 29,48,66 ). The PPE and SCBA worn by firefighters can add up to approximately 21.0 kg (46.2 lbs.) and 11.5 kg (25.3 lbs.), respectively ( 29,48,66 ). Furthermore, load carriage has been associated with the following injuries: foot blisters, stress fractures, back strains, and knee pain ( 43,64 ). Injuries caused by overexertion or strain may indicate that the individual firefighter lacks the physical readiness needed to meet the demands of firefighter tasks. Therefore, regular participation in physical training programs is needed to improve occupational readiness and to prevent the likelihood of injuries. Strength and conditioning is an evidence-based practice that focuses on the key areas needed for enhancing job performance and injury prevention techniques. Consequently, performance professionals (CSCSs and TSAC-Fs) who specialize in strength and conditioning and a sports medicine staff (PTs and ATs) to oversee injury prevention/rehabilitation practices are needed to optimize firefighters' job performance and occupational readiness.

CONSIDERATIONS FOR IMPLEMENTING FIREFIGHTER HUMAN PERFORMANCE OPTIMIZATION AND THE FIREFIGHTER HEALTH AND WELLNESS MODEL

A secondary role of firefighter HPO is to stipulate changes in the firefighter workplace, whereas the FFHWM serves as a resource for guiding fire departments through change. In 2015, Storer and colleagues ( 75 ) sought to determine whether the current physical activity levels and CVD risk factors in a contemporary cohort of firefighters were better than those previously reported over a 30-year timeframe. To no surprise, they found no significant differences and issued a call to action for health and fitness professionals to assist the fire service. These findings are concerning considering that the physical demands, health, and wellness concerns of firefighting is well documented ( 10,16–18,20,21,24–27,30–33,35,37–40,42,46,48–51,53,56,58,61,62,65,66,68–71,74,76,78,81,82 ). To bridge the gap, deep change efforts may be needed to facilitate a paradigm shift. Deep change is the notion that nothing changes unless people change, which is especially true for those who hold leadership roles. Kotter's 8-step change model (8-SCM) ( 44,55 ) is a systematic approach that can be derived from principles of operational excellence and may potentially be a useful tool for facilitating a successful paradigm shift. The 8-SCM, along with examples related to the fire service, can be reviewed using Table 4 . Although the 8-SCM has been effective in a variety of professional settings ( 15,47,54,77,80 ), a collaboration between a supportive fire chief, HPO management, and a champion firefighter(s) may be needed, so the model is adapted for successful integration ( 45 ). It is important to note that these collaborative efforts may serve as an ideal framework for the oversight of a firefighter HPO program.

The FFHWM requires strong leadership to oversee day-to-day operations. This should start with an appointed member of the fire department, such as a chief, captain, or lieutenant. This role may be titled as: Director of Firefighter HPO. Additional firefighters should be recruited to champion the HPO program (i.e., peer fitness trainers) within the fire department. Furthermore, these individuals should be associated with an HPO medical director and HPO program manager—preferably individuals from the interdisciplinary team of professionals. This leadership cadre would help create a synergistic approach to decision-making and tailor the FFHWM to meet the needs of the respective fire department, based on available resources. Moreover, the integration of firefighter HPO and the FFHWM could be a federal or state/district initiative. Because a firefighter HPO program has yet to be implemented, it is difficult to justify the best course of action. The justification for which scenario is most appropriate (state, district, or federal) is outside the scope of this article; however, it is an area that requires further research.

When deciding if the HPO program should be a state/district initiative, it is important to consider the cost justification. Some expenses to consider are annual costs such as the operating budget of the program and employee salaries, whereas up-front costs include weight room/clinical equipment, software programs, and office space and supplies. Some cost benefits to consider are reductions in monthly injuries, injury severity, paid time off, overtime costs, workman compensation claims, and monthly sick calls. There are existing firefighter health and wellness programs that have shown tremendous value to their respective fire departments and municipal governments ( 1,41,60 ). However, the annual cost-saving benefits for firefighter health and wellness programs have not been published in the scientific literature.

Finally, further research may be needed to identify valid and reliable methods for measuring firefighter HPO. Gold-standard and criterion-referenced assessments should be used to evaluate the components of the FFHWM until a more comprehensive assessment to measure firefighter HPO is developed. Assessments and tests used should be carefully selected based on the reliability/validity of tests, operation budget, manpower, scheduling, total test time, available resources, and practical application of results.

HPO and TFF are conceptual frameworks that have been successfully integrated throughout the DoD and may have similar success within the fire service. However, optimizing firefighter human performance requires a distinctive approach. As mentioned previously, firefighting is a physically demanding occupation where physical conditioning, health status, and overall well-being collectively affect an individual's ability to perform their duties. Moreover, the occupational demands differ from those seen in military and athletic settings. The FFHWM was developed to demonstrate the comprehensive relationship of each domain of the HPO seen in Figure 1 and to serve as a framework for current and future firefighter health and wellness programs. These conceptual models are designed to synergistically integrate the domains of health, wellness, and performance to achieve sustained improvements in firefighter job performance, career longevity, and quality of life. Consequently, the concepts of the models are intended to include a team of interdisciplinary professionals, allowing each profession to supplement their knowledge, skills, and abilities with the others so that an all-encompassing service is provided for each individual firefighter. An example of professionals who may support firefighter health and wellness programs can be seen in Table 1 . Services offered in isolation would potentially create fragmentary interventions with suboptimal results. Given the various occupational demands and stressors of firefighting, it is proposed that fire departments begin to adopt a culture of HPO in collaboration with a team of interdisciplinary professionals.

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Firefighter health: a narrative review of occupational threats and countermeasures.

1. Introduction

2. materials and methods, 3.1. physical health threat: cardiovascular disease, 3.2. physical health countermeasure: clinical and fitness assessments, 3.3. physical health countermeasure: exercise, 3.4. physical health countermeasure—dietary intake, 3.5. physical health countermeasure—sleep, 3.6. physical health threat: cancer, 3.7. physical health countermeasure: cancer, 3.8. mental health threat: traumatic events.

“Many firefighters spoke about the impact on their families. […] Reasons given were that they were concerned that their family member might change the way they viewed them as a person because of the kinds of things they were seeing at work. Concurrently, they also wanted their family members to have faith that their role as a firefighter was valuable and that their job was good and important, and they were worried that sharing some of their experiences might undermine their families’ valuation of the job. […] Firefighters acknowledged that the issues that impact their confidence in self and feelings of failure from bad outcomes at work carried over into their feelings within the family. Firefighters also acknowledged awareness and regret that mental health stressors from work carried over into their family life in terms of how they treated family members with less tolerance, irritability, or poor communication. […] They were concerned that taking time off work often compromised their family’s financial stability since sick benefits do not replace usual firefighter income. Many acknowledged the increased risk of divorce in the fire service or had personally experienced divorce and attributed work issues as a contributing factor” (p. 8, 2021) [ 155 ].

3.9. Mental Health Countermeasure: Mindfulness

3.10. mental health countermeasure: post-trauma debriefing, 4. future directions, 5. conclusions, author contributions, institutional review board statement, informed consent statement, conflicts of interest.

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Gonzalez, D.E.; Lanham, S.N.; Martin, S.E.; Cleveland, R.E.; Wilson, T.E.; Langford, E.L.; Abel, M.G. Firefighter Health: A Narrative Review of Occupational Threats and Countermeasures. Healthcare 2024 , 12 , 440. https://doi.org/10.3390/healthcare12040440

Gonzalez DE, Lanham SN, Martin SE, Cleveland RE, Wilson TE, Langford EL, Abel MG. Firefighter Health: A Narrative Review of Occupational Threats and Countermeasures. Healthcare . 2024; 12(4):440. https://doi.org/10.3390/healthcare12040440

Gonzalez, Drew E., Sarah N. Lanham, Steven E. Martin, Richard E. Cleveland, Thad E. Wilson, Emily L. Langford, and Mark G. Abel. 2024. "Firefighter Health: A Narrative Review of Occupational Threats and Countermeasures" Healthcare 12, no. 4: 440. https://doi.org/10.3390/healthcare12040440

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FY2006- Predicting Cardiovascular Risk and Fitness in Firefighters U.S. Department of Homeland Security Award Number EMW-2006-FP-01493

FY2009- Exercise Tolerance as a Predictor of Firefighters Future Risks U.S. Department of Homeland Security Award Number EMW-2009-FP-00835

FY2011- Non-Invasive Identification of Left Ventricular Hypertrophy and Cardiomegaly in Firefighters U.S. Department of Homeland Security Award Number EMW-2011-FP-00663

FY2013- Understanding and Preventing SCD in the Fire Service U.S. Department of Homeland Security Award Number EMW-2013-FP-00749

FY2014- Feeding America’s Bravest: Survival Mediterranean Style – Firefighters’ Mediterranean Diet Intervention U.S. Department of Homeland Security Award Number EMW-2014-FP-00612

FY2017- “Better Heart” (Building Evaluations That Translate Evidence & Research for Health Evaluation & Related Training) Program U.S. Department of Homeland Security, FEMA: Fire Protection & Safety Grant

FY2018- Cancer among Indiana Firefighters: Case-Control Studies U.S. Department of Homeland Security Award Number EMW-2018-FP-00562

FY2020- Surviving & Thriving: Healthy Lifestyle Intervention for New Firefighters U.S. Department of Homeland Security Award Number EMW-2020-FP-00063

Funding Support

The Fire Prevention and Safety Grants (FP&S) are part of the Assistance to Firefighters Grants (AFG) and are under the purview of the Grant Programs Directorate in the Federal Emergency Management Agency.

PI Experience

Stefanos N. Kales MD, MPH, FACP, FACOEM , the principal investigator, is highly experienced in managing this type of project. He has participated in a wide range of research, advisory, and teaching activities on five continents, resulting in over 230 publications and wide recognition nationally and internationally. Dr. Kales’ primary research focuses on the health of firefighters and other public safety professionals, and he has worked with the fire service in particular for over 30 years. He has received Massachusetts, US Federal, and Canadian funding with a proven record of success, producing more than 70 peer-reviewed publications related to firefighting .

Dr. Kales’ group has provided seminal contributions in the clinical epidemiology of cardiovascular events in firefighters and has become most influential in determining the causal relationship of heart disease among firefighters to their job activities and other factors. His group’s work includes the first definitive statistical association of strenuous job tasks and on-duty cardiovascular deaths, which was subsequently confirmed in a later New England Journal of Medicine publication.

As a result of these research efforts, Dr. Kales has influenced national thinking among occupational physicians regarding firefighter’s fitness for duty, the need for improved wellness programs, better control of risk factors, and whether firefighters can safely return to work in the presence of significant coronary heart disease, as well as methods for determining the causal relationship of heart disease among public safety personnel to their job activities and other factors. He was a plenary speaker at the National Fallen Firefighters’ Foundation 2011 summit on these issues, and in 2013, he was presented the Kehoe Award for Excellence in Education and Research in Occupational and Environmental Medicine by the American College of Occupational and Environmental Medicine (ACOEM) for this influential body of work, and the 2014 Harriet Hardy award from the New England College of Occupational & Environmental Medicine, both lifetime achievement awards for outstanding contributions to the field. He has also been recognized with service awards for his research and dedication to firefighter health and fitness by the International Association of Fire Chiefs and with induction as an Officer into the Order of Emperor Dom Pedro II by the Corps of Military Firefighters of Brazil’s Federal District.

Endorsements

These projects have been endorsed by both labor and management with support letters from the International Association of Fire Fighters , International Association of Fire Chiefs , National Fallen Firefighters Foundation , Firefighter Cancer Support Network , The National Volunteer Fire Council , Massachusetts Call Volunteer Firefighters’ Association , Women in Fire , North American Fire Training Directors , and the National Fire Protection Association .

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Exploring the criteria and factors affecting firefighters' resilience: A qualitative study

Affiliations.

• 1 Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
• 2 Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran; Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
• 3 Center of Excellence for Occupational Health, Occupational Health and Safety Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.
• 4 Workplace Health Promotion Research Center (WHPRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Health in Emergencies and Disasters, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Electronic address: [email protected].
• PMID: 34144886
• PMCID: PMC9039426
• DOI: 10.1016/j.cjtee.2021.06.001

Purpose: Firefighters are exposed to high levels of occupational risk factors, such as safety risks, chemical, ergonomic, and physical hazards that may jeopardize their lives. To overcome these hazards, firefighters must be physically, mentally, and personally fit to work. This study aimed to explore the criteria and factors affecting firefighters' resilience based on stakeholders' experiences.

Methods: This qualitative study was carried out using conventional content analysis. In total, 21 face-to-face interviews were conducted by firefighters who were experienced in the field. The interviews were carried out from July 2019 to January 2020. The data were collected using 3 unstructured interviews and then resumed by 18 semi-structured interviews. Data analysis was done using Graneheim method.

Results: The participants had more than 5 years of experience in the field of search and rescue. The extracted codes through data analysis were classified into 3 main categories (individual, organizational, and social factors), 9 sub-categories (mental, physical, occupational, managerial, colleagues-related, equipment-related, environmental, community-related, and family-related factors), as well as 19 sub-sub-categories and 570 codes.

Conclusion: Firefighters' personality, physical condition, behavior and psychological characteristics can affect their resilience along with organizational and management factors that play significant role in people's safety. Developing a tool for assessing resilience can help decision makers to have a real depict of firefighters' job qualifications.

Keywords: Firefighters; Qualitative research; Resilience; Safety.

Copyright © 2021. Production and hosting by Elsevier B.V.

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Conflict of interest statement

Declaration of competing interest The authors declared that there are no conflicts of interest with respect to the research, authorship, and publication of this article.

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• Occupational Hazards in Firefighting: Systematic Literature Review. Cuenca-Lozano MF, Ramírez-García CO. Cuenca-Lozano MF, et al. Saf Health Work. 2023 Mar;14(1):1-9. doi: 10.1016/j.shaw.2023.01.005. Epub 2023 Feb 4. Saf Health Work. 2023. PMID: 36941942 Free PMC article. Review.
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An Interview Study of the Experiences of Firefighters in Regard to Psychological Contract and Stressors

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• Published: 22 February 2018
• Volume 30 , pages 203–226, ( 2018 )

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• Fazeelat Duran   ORCID: orcid.org/0000-0001-6822-6012 1 ,
• Jessica Woodhams 1 &
• Darren Bishopp 1  

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As the first qualitative study of its kind, this study explored firefighters’ beliefs and experiences about the psychological contract between themselves as employees and their employer, workplace stress, stress-management strategies, and their wellbeing. Eleven interviews were conducted with active firefighters from multiple fire stations in the UK. The interviews were recorded and transcribed verbatim. The transcripts were analysed using framework analysis. Five superordinate themes were identified and labelled as ‘Motives’, ‘Mutual obligations’, ‘Stressors and their effects’, ‘Moderators’, and ‘Retention factors’, each of which contained lower level sub-themes. Psychological contract (PC) is a useful construct to measure firefighters’ perceived obligations as their responses reflected multiple facets of PC theory. The current climate of austerity measures appears to be negatively impacting on firefighters in terms of reducing numbers and placing higher task demands on those remaining. Thus, making it very difficult for the UK Fire and Rescue Service (UKFRS) to meet the perceived obligations of their employees. The findings have implications for human resource departments within UKFRS trying to manage the impact of funding cuts and they highlight the potential value of the PC as a construct around which such issues can be explored.

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Firefighting is one of the most stressful occupations with firefighters being exposed to a range of demands, which can impact upon their somatic and mental wellbeing (Beaton et al. 1997 ; Norwood and Rascati 2015 ). The stress they experience is a relevant concern for the many countries around the world that employ them and has been a topic of academic study in several countries, including Japan, the UK, Malaysia, the USA and Canada (Malek et al. 2010 ; Murphy et al. 2002 ; Saijo et al. 2008 ; Sommerfeld et al. 2017 ).

In the UK in particular, industrial relations are a pressing matter within the organisational climate of UK firefighting (Brunsden and Hill 2009 ). Since 2010, UK Fire and Rescue Services (UKFRSs) are facing budget cuts as a result of austerity measures. In the last few years, the UK Government has reduced the funding received by the UKFRSs by 30% (CFOA 2012 ). At present, the austerity cuts facing UKFRSs have yet to be fully implemented, however, already there has been a reduction in the number of full-time retained and control firefighters. Specifically in England, the total number of firefighters has decreased by 3.2% in 2015 and by 14.7% between 2005 and 2015 (Bega 2010 ; Gaught 2016 ). Greenwood ( 2016 ) has estimated that the UKFRSs could lose up to 10,000 more firefighters by 2020. This may, in part, be due to the overall downtrend in the number of fires that are attended to on an annual basis as shown in Appendix Fig. 1 , produced from the national statistics (Home Office, 2014 ).

Regardless of the trend in the reduction of fires, the UKFRS remains critical to public safety and it is timely to study how actions by the Government, and the implementation of these by the employer, might act as a stressor affecting the wellbeing of UK firefighters. A reduction in the number of firefighters isn’t a concern limited to the UK. In the US, the total number of volunteer firefighters now exceeds the number of career firefighters and even the number of volunteers per 1000 of the population is decreasing (Haynes and Stein 2016 ). The present study therefore aimed to understand the experiences of firefighters working in the UK, and explores their psychological contract (PC) in the austerity climate and its impact on their stress and wellbeing.

There are number of incident-related stressors faced by Fire Service personnel that can affect their mental and physical health including time pressure, lack of sleep, fatigue, high stakes decision making, risk of injury to self or death, and exposure to other people’s trauma (Bos et al. 2004 ; Murphy et al. 2002 ). The National Institute for Occupational Safety and Health ( 2004 ) has attributed an increase in deaths of firefighters to cardiac arrest and high blood pressure (Kales et al. 2009 ), and they are noted to suffer from weakened immune systems, musculoskeletal difficulties, and fatigue (Cohen and Herbert 1996 ). A common reason for leaving the Fire Service for retirement or early retirement is ill-health (Gaught 2016 ). Moreover, Stanley et al. ( 2015 ) have found a high risk of suicide among firefighters.

In addition to incident-related stressors, there are a host of organisational stressors that firefighters can be exposed to, which include shift patterns, overtime, excessive workload, departmental politics, harassment, poor organisational climate, poor communication, lack of training, and conflicts with co-workers and supervisors (Brough 2004 ; Brunsden et al. 2003 ; Saijo et al. 2008 ). These stressors can have long-term psychophysical and behavioural effects on the health of firefighters, for example, anxiety and depression (Brough 2004 ); burnout (Prati et al. 2011 ; Vaulerin et al. 2016 ); emotional exhaustion (Smith et al. 2003 ); depersonalisation (Alexander and Klien 2001 ); and post-traumatic stress disorder (McFarlane and Bryant 2007 ).

While there is evidence for a relationship between workplace stressors and poor psychological health with samples of firefighters (Brunsden et al. 2003 ; Prati et al. 2011 ; Saijo et al. 2008 ; Vaulerin et al. 2016 ), there is also the potential that such a relationship can be mediated by other positive factors. Factors such as social support, self-efficacy, coping strategies, maintaining a work/family and/or work/leisure balance, mindfulness training and resilience have all been identified as potential mediators of chronic and complex stressors in the workplace (Carpenter et al. 2015 ; Cowman et al. 2004 ; Halbesleben 2009 ; Khoury et al. 2013 ; Lambert et al. 2012 ; Lee et al. 2014 ; Regehr et al. 2003 ; Wong et al. 2014 ). The current study therefore sought to understand what incident-related and organisational stressors were being experienced by UK firefighters, as well as improve our understanding of what factors might help them buffer or manage the effects of workplace stress on their wellbeing.

As well as potentially having a negative impact on the employee, organisational stressors are also associated with negative outcomes for the organisation itself, e.g., poor job satisfaction and subsequent staff turnover and absenteeism (Brough 2004 ). A comprehensive understanding of employee-employer relationships within firefighting organisations can help determine ways to tackle such organisational stressors. An area that has received less attention to date is the social exchange construct of ‘psychological contract’ (PC). It refers to “a person’s beliefs regarding the terms and conditions of the reciprocal exchange agreement between themselves and their organisation” (Rousseau 1989 , p. 123). This construct focuses on unwritten expectations, beliefs, promises or obligations between employees and employers beyond the actual written agreement (Inocencia 2012 ). Rousseau ( 1990 , 1995 ) categorised the perceived obligations into transactional and relational obligations. Transactional refers to obligations that are extrinsic, that occur in a close-ended time frame, that are static and observable (e.g., pay and reward). In contrast, relational obligations are more open-ended, intrinsic, dynamic and subjective (e.g., job security) (Conway and Briner 2009 ; Rousseau and McLean Parks 1993 ). PC therefore covers a range of issues like trust, fairness, promotion, training, development and decision making (Conway and Briner 2005 ; Turnley and Feldman 2000 ). Studies of work-related stress have argued that breaches and violations of PC can make a significant contribution to the stress experienced by employees (Noblet et al. 2009 ). PC fulfilment has been found to predict job and life satisfaction (De Cuyper et al. 2011 ), resistance to change (Van de Heuvel and Schalk 2009 ); and the level of trust and fairness between employees and employers (Van der Vaart et al. 2015 ; Van der Vaart et al. 2013 ). Organisations that fulfill employees’ PC have low work-related anxiety and depression, and job insecurity (Guest et al. 2010 ). The employer’s fulfilment of obligations affects the employee’s intentions regarding whether to resign or stay with an organisation (De Cuyper and De Witte 2006 ; Flood et al. 2001 ). In contrast, when employees’ perceived obligations are broken it results in negative organisational outcomes such as increased turn over intentions, organisational distrust, and job dissatisfaction (Wayne et al. 2007 ).

Previous literature has linked PC breach to Social Exchange Theory (Blau 1964 ), which states that employees try to achieve a balance in the exchange between themselves and their employer, for example, employees work hard and in return expect to be recognised for their efforts. When the employees perceive imbalance in the fulfillment of perceived obligations, there are negative consequences. Similarly, PC breach could be linked to stress and wellbeing from a conservation of resources theory (COR) perspective. This theory states that an individual protects his/her required resources (money, health, etc.) and that perception or actual loss of such resources can trigger negative consequences (Halbesleben and Bowler 2007 ; Hobfoll 1989 , 2001 ). Consistent with this theory, we argue that unmet obligations perceived as a loss of valued resources (Restubog et al. 2013 ) could be linked to stress and wellbeing. In high-stress jobs such as firefighting, a fulfilled PC might be one way to ameliorate the stress experienced by employees.

While there is a substantial literature on PC with employees and employers from the educational, retail, and commercial sectors, the authors could only identify three studies, which had examined this construct with firefighters (Coyle-Shapiro 2002 ; Coyle-Shapiro and Kessler 2003 ; Liao-Troth 2005 ). Liao-Troth sampled 85 volunteer firefighters in the US and investigated the relationship between PC formation and individual motives (such as career, values, and protection) that would imply loyalty for a longer period within the organization. No association was found between the PC type and motives, perhaps because volunteer rather than full-time, career firefighters were sampled.

In the UK, Coyle-Shapiro ( 2002 ) and Coyle-Shapiro and Kessler ( 2003 ) applied the PC construct to two samples of public sector employees of 480 and 5709, respectively, to study the effects of perceived PC fulfilment on their attitude and behaviour. PC fulfilment was found to be a predictor of public sector employees’ organisational commitment and organisational citizenship behaviour. However, only 40 and 211 of the participants were firefighters, which equates to 4% and 8% of each sample, respectively. Therefore, it is difficult to know to what extent the findings apply to firefighters, specifically.

Each of these existing studies with firefighters has used quantitative methods to measure PC. To the authors’ knowledge, no previous study has utilised qualitative methods to explore how PC and the consequences of broken obligations or promises are experienced by firefighters. Therefore, the potential contribution of this study is its qualitative design and the unique sample of firefighters: this could add more detail to the otherwise dominant stream of quantitative studies among more common segments of the labour market. In the current climate of budget cuts, the outcome of the study would assist the management of UKFRS because they play an essential role in managing the PC of their firefighters. A qualitative study provides greater detail in terms of whether firefighters have different reactions to PC breach or are alike other professions. It is also important to conduct such a study because tests devised to measure PC (e.g., PSYCONES 2005 ; Rousseau 1990 , 2000 ) have been developed with employees from the commercial, educational and retail sectors and have yet to be validated with employees from the emergency services. Therefore, the current study took a qualitative approach to address this gap in the literature.

The current study aimed to fill a gap in the literature by examining UK full-time firefighters’ beliefs about mutual obligations stemming from social-cultural context. It is an uncertain time in the UK for firefighters, where taking positive actions to improve their experiences could be important. We also aimed to examine the stressors experienced by UK firefighters; this was because most studies of emergency personnel focus on the causes and effects of stress amongst police officers and paramedics, rather than firefighters (Larsson et al. 2016 ; Malek et al. 2010 ). They are, therefore, a relatively neglected group.

Participants and Recruitment

Participants were recruited from 11 different fire stations from within one English county. The recruitment process utilised a variety of methods including electronic and face-to-face meetings with watch commanders and firefighters. In addition, the Fire and Rescue Service Human Resource Department circulated an electronic recruitment letter to different fire stations across the county. The participants also aided recruitment by snowballing information about the study to colleagues through social networking.

In total, 11 full-time, active, front-line firefighters participated. The ethnicity of all interviewees was White, and all except one were male. Four were single and seven were married or in a relationship. Their length of operational service ranged from 1.5 years to 12.5 years. They were watch commanders ( n  = 2) and firefighters ( n  = 9).

A semi-structured interview was conducted with each participant on an individual basis. At the start of the interview, demographic information was collected from the interviewee regarding their gender, ethnicity, marital status, job title, number of years worked in the Fire and Rescue Service, and number of hours worked per week. The remainder of the interview schedule consisted of open-ended questions, which defined areas to be explored, but which also allowed for flexibility to discuss emerging issues. With regard to PC, the interview schedule included questions about firefighters’ expectations regarding their job and employer with prompts and further questions (in some cases) related to obligations commonly mentioned in the PC literature such as development and training opportunities, and sources of support. These questions were open-ended allowing the interviewees to cover relational and/or transactional obligations. In recognition of the reciprocal nature of PC, we asked about perceived obligations of the employee as well as of the employer, whether these were being met and, if not, why not. The flexibility of a semi-structured interview enabled us to ask follow-up questions about obligations raised by the interviewee, which did not feature in the interview schedule. In light of the association between PC fulfillment and positive outcomes as well as PC breach and violation with negative outcomes, we also asked interviewees about the positive and negative impact of their job and explored the stressors they experienced and what strategies and resources were available to them to tackle these (see Appendix Table  1 ).

Ethical approval for the study was obtained from the Science, Technology, Engineering and Mathematics (STEM) Research Ethics Committee. Before the commencement of the interview, the participant information sheet and consent form was provided to the participants. Their consent was obtained for the interview being audio recorded. Interviews were conducted either at the firefighter’s workplace ( n  = 6) or over the telephone ( n  = 5). The mean interview length was 51 min (range: 42–56). There were no differences between the face-to-face and telephone interviews in relation to length of interview. Participants were given a £20 Love-to-Shop voucher on completion of the interview. Due to the topic of the interview, each participant was given the contact details of their occupational psychologist at work so that they could seek help, if needed. Participants were given two weeks post-interview to withdraw from the study. Once this time had passed the audio files were transcribed verbatim (replacing names with pseudonyms) and deleted.

Data Analysis Strategy

Framework analysis (Gale et al. 2013 ; Ritchie and Lewis 2003 ; Ritchie and Spencer 1994 ) was chosen as the method of analysis since it is a systematic approach to analysis but also allows for changes to be made to the coding framework during the analytical process. Further, themes can be constructed at multiple levels. Themes are developed from the data and not a-priori. QSR Nvivo10 was used to manage the data while ensuring the analyst could still view the original material. Each respondent was allocated a row while sub-headings were organised into separate columns. Each transcript was analysed by coding the data into base units of meaning and creating free codes. These free codes were further categorised into logical themes. The generated themes for each participant were incorporated across participants to produce a list of high order categorised themes capturing shared experiences of the participants. The authors scrutinised the relationships and interactions between the themes in the chart to explain the beliefs and experiences of the firefighters sampled (Ritchie and Lewis 2003 ; Ritchie et al. 2013 ).

Results and Discussion

Five main themes were identified and were labelled ‘Motives’, ‘Mutual obligations’, ‘Stressors and their effects’, ‘Moderators’, ‘Retention factors’ (see Appendix Table  2 ). Each of these themes served as an umbrella theme for high-order categories. Further, these high-order themes consisted of lower-order categories and then base units of meaning. How these levels were arranged can be seen in Appendix Table  3 . Moreover, how often each lower-order category and each base unit was referred to in the interviews and by interviewee is included in Appendix Table  3 .

Theme 1: Motives

This theme encapsulated each of the participants’ reasons for joining the Fire and Rescue Service. Within it, there were six sub-themes. ‘Life time aspiration’ accounted for more than two-thirds of all responses.

It was my passion to join the Fire Service from my childhood because it is an exciting job. I never thought of any other job really (Female, Firefighter 1).

The other reasons for joining the Fire Service included firefighting not being a typical job with typical hours (i.e., ‘not a 9–5 job’) and it having ‘better career opportunities’ than other jobs.

I wanted to do something that was different from the routine. By routine I mean 9 – 5 jobs and there would be not a single day that is the same. (Male, Firefighter 7). I opted for the Fire Service really; when I wanted a change...This profession provides a better career in comparison to other job structures (Male, Watch Commander 10).

Further, approximately half of the interviewees referred to the UKFRS having a generous pension scheme in comparison to other professions as a reason of joining. These officers would have joined UKFRSs prior to the implementation of financial cuts.

I chose to be a firefighter because I want to have a better living standard when I retire (Male, Watch Commander 10).

Interviewees also commented that a reason for joining was that ‘not everyone can be a firefighter’, which suggests the job has a special status associated with it, which gives them a feeling of pride and achievement.

I always wanted to purse this job, as it is very difficult to get into this job. (Male, Firefighter 3). ...because not everyone can get into this job easily, just like the army (Male, Watch Commander, 10).

Moreover, there was one participant who joined because of ‘family tradition’ i.e., his relatives were part of the Fire and Rescue Service and he grew up hearing fire-fighting stories.

My uncle was a firefighter and hearing his stories developed my interest to join this profession. It took me quite a long time to get into this job, as I wanted to join the Fire Service when I was 15 years old (Male, Watch Commander 8).

From the above, it was clear that motives for joining the Fire and Rescue Service would likely be associated with PC breach because some of the employees had joined with the perceived obligations of having better pension schemes, as compared to other professions. However, in the current climate of austerity cuts in the UK, and with the Government having brought in changes to firefighters’ pension schemes in 2011 (CFOA 2012 ), it is likely that such perceptions are difficult for the Fire and Rescue Service, as the employer, to satisfy. Therefore, the cuts act as an external force triggering PC breach by the Fire and Rescue Service meaning the organisation can no longer fulfil its perceived obligations (Thompson and Bunderson 2001 ).

Theme 2: Mutual Obligations

This theme captured firefighters’ perceptions of what the perceived obligations were of their employers (‘employer obligations’) and their beliefs of what their employers would expect of them (‘employee obligations’) (see Appendix Table  2 ). There were eight employer obligations that could be further categorised into relational and transactional obligations (Bunderson 2001 ; Rousseau 1990 , 2000 ), and five employee obligations towards their employer, which were further categorised into the obligations of ‘loyalty’, and ‘looking after property’.

Employer Obligations

In terms of transactional obligations, more than half of the firefighters perceived to be provided with a safe working environment by the employer, which was related to the employer providing appropriate and sufficient equipment. In addition, they spoke about the need for the employer to provide the right equipment to allow them to perform their duties with professionalism. Moreover, two of the participants spoke about financial rewards. Specifically, they talked about their belief that they would receive their pay on time and that they would be provided with a good pension scheme.

We want to be paid at the end of the day, as we need money for our living. We need a good pension scheme as well (Male, Watch Commander 10)

In addition, firefighters spoke about relational obligations (Rousseau 1990 , 2000 ): three of the interviewees expected there to be parity in how themselves and their colleagues were treated. They talked about the stress, demands and responsibility associated with the job and that they accepted these providing they received financial security now and in the future. Cuts in the budgets of the Fire Service meant that the frontline firefighters we sampled were concerned about their job security.

I want to be treated fairly by my employer as the rest of the employees are treated. My bosses and supervisors should keep a check on whether we are treated fairly... (Male, Firefighter 4). I expect to have a secure job when we are facing budget cuts. I want quite a secure job in terms of how long I will be protected from redundancy (Male, Firefighter 8).

Four of them referred to beliefs that their employer respect them and understand their position, as they were once at a similar stage of career.

They should realise that once they were also a firefighter. They [seniors] should respect us (Male, Firefighter 6).

Further, three firefighters expected that their employer would provide them with opportunities for advancement and growth, or training to develop into a competent firefighter, so that they are up-to-date in their job role. It was felt that this would enable them to tackle difficult situations in a professional manner.

I want to have good training in order to deal with serious incidents... So, to develop into a competent firefighter, I need more training. This will assist me to grow in my role by being a fully competent firefighter (Male, Firefighter 5).

Three of them mentioned that they want to be provided with assistance when they are struggling with a task.

Sometimes, I want them to help me, when I am struggling with something. By something’ I mean anything that is related to performing the duty with excellence (Male, Firefighter 11).

Three-quarters of the interviewees perceived that, most of the time, employers met their perceived obligations by, for example, providing training. They also mentioned that they were treated the same way as other employees within the organisation. A point they were concerned about, however, was the skills of higher management within their organisation.

I am unhappy with the selection of our senior leaders. The reason is you [high ranking officials] are selecting the people on the basis of practical skills no matter how goofy their management skills are (Male, Firefighter 3).

Employee Obligations

In terms of ‘employee obligations’, 90% of the interviewees felt that they fulfilled their employer’s perceived promises by being ‘loyal’ (Bunderson 2001 ; Herriot et al. 1997 ) to the organisation, i.e., protecting the core values of the Fire and Rescue Service (being punctual, maintaining competencies, being a good team player, and performing duties with loyalty to the Fire Service). Moreover, the employers were perceived to have an expectation of their employees that equipment would be cared for (Herriot et al. 1997 ) and that the station would be kept clean and tidy.

My employers just want me to promote and preserve the core values of the Fire Service. These core values are definitely to perform well when a certain task is given. All the firefighters have to keep the stations clean and tidy and maintain unity within our team (Male, Firefighter 11).

One-third of the firefighters perceived their employers’ obligations of them to have changed from the time they started in the job. This is consistent with previous literature (Conway and Briner 2009 ; De Meuse et al. 2001 ; Robinson et al. 1994 ), which suggests that the PC changes with time. However, the firefighters interviewed seemed to suggest that this wasn’t a positive change and that they were now overwhelmed by the different duties required of them.

The way we do the job has changed a lot these days. It’s much like we not only have to attend the incidents but also educate children. There is so much to do rather than dealing with the fire calls (Male, Watch Commander, 10).

PCs can be classified as relational or transactional (Rousseau and Tijoriwala 1998 ; Rousseau 2000 ). As noted above, employer obligations reported by our participants represent both transactional and relational elements because they refer to monetary and non-monetary exchanges within an open-ended agreement (Rousseau 1990 ). However, the obligations referred to by the majority of interviewees are relational because they are implicit and subjective with no clear time frame (Conway and Briner 2009 ). This is most likely because the firefighters sampled were all full-time (career) firefighters as opposed to part-time or volunteers, whose PCs are more transactional in nature. Furthermore, a few interviewees perceived a decrease in the relational component of their PC with their employer over time, in terms of reduced levels of respect, and a reduced commitment to the organisation (much alike De Meuse et al. 2001 ).

In terms of how the experiences of our interviewees mapped onto aspects of PC measured by existing tests, the obligations mentioned by the firefighters, such as receiving a good rate of pay, having job security, being treated fairly by the employers, and being provided with opportunities for advancement and personal growth, are similar to how employer obligations are measured in PSYCONES ( 2005 ) and Bunderson’s ( 2001 ) measure of PC. These measures were developed with employees from the commercial, retail, educational and health care sectors, therefore these findings suggest that firefighters perceive similar obligations from their employers as employees in other sectors.

PC breach refers to when employees perceived their obligations to be unfulfilled. Within the interviews, there was some evidence that firefighters perceived a breach to their PC with their employer (Morrison and Robinson 1997 ). However, rather than the firefighters referring to the Fire and Rescue Service having breached the contract, their actual employer, they instead referred to the Government as the cause of the breach. So, while the employees were largely happy with their employer (the Fire and Rescue Service), three-quarters of the interviewees were unhappy with the Government, who they perceived to be the cause of the current industrial action.

...Firefighters might be happy with their employers but they are not happy and satisfied with the Government. This is leading to massive strikes.... (Male, Firefighter 7).

Within the interviews, having to “do more” was often spoken about alongside comments regarding the “financial strains” being experienced by the Fire and Rescue Service. This suggests that the increased number of tasks facing the firefighters might also stem from the reduction in their numbers (i.e., fewer personnel having to do more with less). Other quotes from the interviewees implied a general sense of feeling under-resourced with the implication being that numbers could reduce further as people left the Service. This seemed to implicate a breach in the PC from the employees’ perspective:

In previous years, the number of firefighters is going down. There are fewer fire engines... we have a lot of financial strains these days. If these continue, we are further going to go down in numbers (Male, Watch Commander 10).

As noted above, several of the firefighters referred to the “good pension scheme” as a reason for joining the Service and that receiving a good pension was an obligation they perceived their employer to fulfil. However, approximately 80% of the firefighters referred in negative terms to the UK Government making changes to the pension scheme within the Fire Service during their interviews:

The Government is not right by bringing change in the pension scheme (Male, Firefighter 6).

Further suggestions of breaches to their PCs lay in comments which implied they did not feel recompensed sufficiently for the challenging job they undertook, and that they were not being given sufficient resource to perform their job adequately (i.e., insufficient staffing and inadequate equipment).

It’s because we work hard, giving our best, therefore we should be paid for it (Male, Watch Commander 8). They (the Government) want to save money by having cuts in our budget...hmmm because of this; we have lots of financial strains and few firefighters, today. There are also fewer fire engines (Male, Firefighter 6). The public needs to be aware of what the Government is doing with the firefighters (Male, Watch Commander 8).

As a public service, the Fire Service extends the traditional model of a PC between employer-employees since, while firefighters have an immediate employer (the Fire Service), they are also employed by the Government (Dick 2006 ). Further, while they have obligations to their employer, these extend to providing a service to the public. The public can have their own expectations of firefighters and the Fire Service, which may or may not be met. The quotes from the firefighters we sampled imply that firefighters are aware of this and so wish the public to be aware of the difficult circumstances in which they are operating should they not be meeting the public’s expectations.

Theme 3: Stressors and their Effects

There were a number of stressors cited by the firefighters we interviewed; family/personal, organisational (circumstances within the organisation that cause stress, such as high workload, etc.), incident-related (stressors resulting from attending an incident at work), and government stressors. These stressors were identified as having a negative impact on the physical and psychological wellbeing of the firefighters in the current organisational climate of UKFRSs (see Appendix Table  3 ). The primary source of stress as perceived by the firefighters was referred to as ‘the Government’:

They (the Government) are causing stress by messing with our finances, messing with our pensions, messing with our retirement wages (Male, Watch Commander 8).

Another type of stressor faced by the interviewees was a personal stressor related to ‘family problems’. More than half of the employees reported having insufficient time for family, holidays and festivals. One interviewee spoke about being unable to find any leisure time for him/herself (‘personal stressor’) and several talked about the difficulties of maintaining a good balance between work, home and social life. This seemed particularly relevant to participants who were in a relationship or had a family. In contrast, the employees who were not in a relationship or who were single were more satisfied in terms of their work-life balance. These findings resonate with Conway and Briner ( 2009 ) and Millward ( 2006 ) who found that events such as marriage and parenthood influence or change an employee’s perceived obligations from their employer.

I am unable to make up for holidays and festivals due to my job commitments. I have no time for a social life, honestly. At times, it gets difficult for me to have a balance between my work and home (Male, Firefighter 9).

One-quarter of the firefighters reported ‘incident-related’ stressors such as dealing with fires, false alarms, dealing with members of the public on the scene, and being distracted from their work by members of the public’s interference. Furthermore, it was distressing for these employees when, at times, they were unable to help people involved in the incident. It seemed that incident-related stressors were not linked to PC breach.

It gets really difficult to deal with the public as they come up with their cameras and make videos. Even though, when they are asked to move back politely, they never listen to you. They think it’s like we are not doing anything serious or it’s not a serious job, but it is really distracting and disturbing (Male, Firefighter 5). Sometimes you deal with nasty incidents and nasty people so it gets stressful (Male, Firefighter 4).

The firefighters interviewed reported facing ‘organisational stressors’, namely large amounts of paperwork, team conflicts, shift patterns (four days on and four days off), and difficulties with time management. An additional organisational stressor reported by the interviewees was a reduction in numbers of firefighters - too few firefighters puts pressure on the remaining staff to fulfil the duties required of them. This is consistent with existing literature (Gaught 2016 ) with one implication being that in future there might be further reductions in the number of firefighters.

The industrial action will make terms and conditions more difficult. Already we are dropping in numbers and our job is important in order to protect the community. I find this stressful... (Male, Firefighter, 11).

It was evident from the quotations that, unlike incident-related stressors, personal, government and organisational stressors were linked to PC breach that might subsequently have a negative impact on the firefighters’ wellbeing.

Effects of Stressors

As a consequence of these incident-related, organisational and personal stressors, the employees reported experiencing ‘physical distress’ including being tired and run-down. Lack of sleep/poor sleep was a common consequence of organisational stressors (i.e., shift patterns).

When I come from the night shift it gets difficult for me to get rest (Male, Firefighter, 4). Sometimes, I am a bit tired when I am unable to manage work life and social life and shift pattern. I run down to a point that I do not have rest and this affects my sleeping pattern as well. I don’t get enough sleep. (Male, Watch Commander 10).

The shift pattern being a stressor is consistent with some previous research where it was attributed to causing physical distress (Bos et al. 2004 ; Murphy et al. 2002 ). In contrast, Litchfield and Hinckley ( 2016 ) didn’t find such a relationship but found that a different shift pattern (of two days and two nights on and four days off) was associated with a better work-life balance amongst firefighters.

Incident-related stressors were more often associated with muscular discomfort and pain, injuries and falling sick. A few of the interviewees reported experiencing ‘psychological distress’, namely mild anxiety and depression, due to personal/family stressors, in particular having no time for themselves or family. For two interviewees, their intimate relationship with a partner had also ended because they were unable to balance work and home life. Firefighters also mentioned emotional or physical exhaustion resulting from the demands of the job. In addition, Halbesleben ( 2009 ) found that emotional exhaustion could result from work-family conflict.

I found myself exhausted by push and pull. In this environment, I was suffering from mild anxiety and stress affecting my sleep, life, and mood. I was unable to manage work life and home life. I was unable to give time when my kids wanted me (Male, Firefighter 4).

Our findings accord with previous conclusions about firefighters facing organisational stressors, family stressors (Brunsden et al. 2014 ), and incident-related stressors (Brown et al. 2002 ). In addition, our sample referred to stressors attributed to the Government. This was considered as an external stressor acting on the Fire Service as an employer preventing fulfillment of employees’ perceived obligations, such as having a good pension, and sufficient workforce and resources.

Theme 4: Moderators

Several factors were cited by the interviewees as being utilised to manage stress in the job. These were grouped under ‘moderators’ (alike Dean et al. 2003 ; Regher et al. 2003 ). ‘Social support’ was quoted by all the firefighters as the best method to buffer the effects of stress. This accords with previous literature that has cited social support as a buffer for high stress levels (Haslam and Mallon 2003 ; Young et al. 2014 ). Interviewees reported that there were sufficient resources within the organisation to offer social support when needed (i.e., ‘organisational support’). These sources included the occupational health department, their watch colleagues, the Watch Commander and the Union. Our findings suggested that all the employees felt they had adequate social support irrespective of their length of the experience, whereas Regher et al. ( 2003 ) found newly recruited firefighters received more support than experienced firefighters. Moreover, alike Young et al.’s ( 2014 ) findings, the interviewees that had less experience particularly mentioned seeking social support from more experienced members of the watch as a way of managing distress.

There is also an occupational health department, who deal with our stressors. Everyone supports each other at watch level. I also belong to the union and my union supports me in case of dealing with stress (Male, Firefighter 11).

Mixed reports were given of drawing on external sources of social support, such as from families, friends and relatives, to buffer the effects of stress. A few interviewees mentioned that they would prefer not to talk to their family because of the distressing nature of incidents they work with and to avoid their families worrying about them at work. Similar findings were reported by Menendez et al. ( 2006 ) and Yoo and Matsui ( 2012 ).

I have got enough support from my family and friends, but I can’t share with them everything as they can be taken aback with this role, I don't want them feel bad and concerned about me when I am at work (Male, Firefighter 11).

However, there were a few firefighters who did seek support from friends and family, although they again seemed to indicate a preference for talking with work colleagues, perhaps due to their immediate availability after an incident, as alluded to below:

I talk to my partner and friends and I also talk to my colleagues. They are the people we interact with immediately after the incident (Male, Watch Commander 10).

Similarly, Brunsden et al. ( 2014 ) found that firefighters prefer to seek support from colleagues because they spend most of their time at the fire stations and their colleagues are, therefore, the people they encounter after attending a fire incident. In addition, family members who were part of the firefighting family provided an extension of such support:

I think I am quite lucky that I have family and friends who support me. I come from a firefighter family... (Male, Firefighter 3).

A range of approaches were used to manage stressors, beyond drawing on social support. A minority of interviewees reported using ‘avoidance’ strategies such as diverting attention from a source of stress by engaging in another activity (e.g., going to the cinema), or focusing on resolving the issue while at the incident itself. One interviewee spoke about the use of alcohol by colleagues to cope. Brown et al. ( 2002 ) investigated the coping strategies of Irish firefighters and found that they resorted to avoidance strategies during period of distress.

A few of the interviewees seemed to use ‘mindfulness’ (Walach et al. 2007 ) as a coping strategy: they reported not becoming easily stressed or they reported accepting that stressors were part of the job. Mindfulness has been reported to be a beneficial strategy in overcoming anxiety and depression, and for improving relationships (Khoury et al. 2013 ). Other studies have reported the beneficial effects of mindfulness techniques for coping with stress with US military service personnel (Jha et al. 2017 ), and emergency room nurses (Westphal et al. 2015 ).

Theme 5: Retention Factors

Besides interviewees finding being a firefighter a challenging job for the range of reasons outlined above and some of them reporting a breach to their PC, the employees enjoyed being part of the Fire Service. The ‘retention factors’ that had meant they hadn’t left the Fire Service were; job diversity, helping people involved in incidents, educating children, and colleagues becoming part of their social network. Moreover, employees experienced positive ‘personal changes’ within themselves. They reported that they had developed more awareness of their surroundings with time, in terms of being more aware of the causes of fires and other incidents and therefore they take steps to protect themselves and their families. They have become more accomplished at dealing with emergency situations potentially due to their coping strategies having changed over time. Moreover, one of them mentioned becoming more vigilant. Whether this is a positive change is unclear since being hypervigilant can inhibit relaxation (Sommerfeld et al. 2017 ).

When I am in public surroundings, I always keep myself aware of any emergency incident that might take place. I think what actions I need to take and how I need to deal with the situation, hmmm... how to save people (Female, Firefighter 1).

Four firefighters felt they had developed personally to become more confident, competent, mature and responsible. They described how they had learned to control their nerves and that they had become stronger emotionally.

I have built up my confidence. By confidence I mean my social skills are improved a lot when I am within a social gathering (Male, Firefighter 11). I consider I am more responsible person. I think I probably know how to deal if something goes wrong (Male, Firefighter 5).

A few of the interviewees reported that they had now learned how to balance work-life demands and that that had come with experience.

It is very convenient for me to balance between family and work life now after these many years. I do not have any family issues. I know how to draw a line between work and home (Male, Watch Commander 8).

General Discussion

The present study aimed to understand the experiences of firefighters working in the UK, and explores their PC in a climate of austerity and its impact on their stress and wellbeing. When asked about their expectations of their employer and the obligations that their employer should meet, evidence of both transactional and relational obligations was forthcoming (Rousseau 1990 , 1995 ). The sorts of obligations cited by our participants overlapped with those cited by employees in other sectors that have formed the basis for the development of measures of PC (e.g., Bunderson 2001 ; Herriot et al. 1997 ; PSYCONES 2005 ; Rousseau 1990 , 2000 ), for example, receiving a good rate of pay, having job security, being treated fairly by the employers, and being provided with opportunities for advancement and personal growth (Guest et al. 2010 ). This suggests that quantitative measures of PC, such as these listed, should be applicable for use with firefighters.

The climate of austerity cuts in the UK and its impact on the UKFRS was thought to make this a particularly relevant time at which to consider the importance of the PC with firefighters due to its theoretical links with stress, mental wellbeing and workforce behaviour (e.g., retention). From the interviews, it was apparent that firefighters were experiencing breaches to their PC regarding being suitably recompensed for the difficult job they do, and having insufficient resources (physical and human) to conduct their role to the best of their ability. Reactions to perceived breaches of PC differ depending on the type of PC (Robinson et al. 1994 ). Employees with a relational contract are at greater risk of severe PC breach (Grimmer and Oddy 2007 ). Moreover, if an employee continues to work within the organisation after a perceived breach of PC has occurred, the contract is likely to become more transactional in nature (Atkinson 2007 ; Pate et al. 2003 ). Therefore, in the current scenario, where the UKFRS is facing austerity cuts, and as a result of these cuts the employers are unable to fulfil the perceived obligations of their employees (e.g., providing a good pension schemes), it is likely that firefighters will develop a more transactional PC (short-term and focused on monetary exchanges) (Lester et al. 2007 ). As per Blau’s ( 1964 ) Social Exchange Theory, employees try to achieve a balance in the exchange between themselves and their employer, for example, expecting suitable recompense (current and future) for the demanding and dangerous job they do. When there is an imbalance, which looks unlikely to be redressed, negative consequences such as resignation can result. Other reactions to broken promises or obligations can include employees taking action that breaches their obligations to their employer (Zhao et al. 2007 ), such as participating in industrial action. It was evident that PC breach was associated with stressors and psychological distress. This is in line with COR theory (Hobfoll 1989 ) suggesting that PC breach results in stress and impacts wellbeing when the employees’ valuable resources (i.e., perceived employer obligations) are not sustained.

The findings from this study suggest that the PC of an employee is not just shaped by their employer or organisation, but also by the Government, media, and public. Further, the perceived obligations of the employer can change depending on the broader context of the employee, such as becoming a parent or getting married.

The firefighters sampled in this paper varied in terms of their length of service and this provided the opportunity to compare themes that emerged in the interviews of experienced firefighters compared to newer recruits. Length of service appeared to be associated with the type of obligations cited by the firefighters as well as their responses to other areas of the interview. In terms of PC, the obligation cited by firefighters with less than three years’ experience related to advancement and growth, as compared to those with more years of service who focused more on training and development, and relational obligations. This difference could be explained by new recruits being more focused on becoming a ‘competent firefighter’. With regards to stressors, newer recruits discussed incident-related stressors more than experienced firefighters (e.g., difficulties dealing with the public on the scene and being distracted by public interference). Also, it was these interviewees who reported the distress experienced when they were unable to help someone at an incident. Their focus on becoming a competent firefighter might be in response to experiencing the stress associated with such situations which they assume will pass with growing experience and competence. These findings coupled with the newer recruits explaining how they have developed over time indicate the value of a future study that investigates changes in the PC, stressors and coping over time with participants from the Fire and Rescue Service.

Limitations

There were some limitations in this study that need to be acknowledged. The sample cannot be considered representative of all U.K. firefighters because the sample size was small and limited to one geographical area of the U.K. Further, the study focused on the employees’ perspectives only (a unilateral approach to PC) therefore a future study should also examine the perspective of the employer and/or the occupational health department.

Implications

This paper makes a theoretical contribution to the literature by providing support for the theory of PC with an understudied population, suggesting that existing measures of PC should be suitable for use with firefighters. It also highlights how, within some sectors, the notion of one employer is too simplistic with employees perceiving themselves as having obligations to others beyond their immediate employer (i.e., to the public), and others beyond their immediate employer having obligations to them (e.g., the Government).

Austerity cuts are not something that the firefighters’ direct employer (the UKFRS) has control over, therefore, it’s important to consider what the employer could still do to address breaches in PC. The employer could, for example, foster closeness between employees and ensure opportunities for career development and recognition (Ebadan and Winstanley 1997 ; Nadin and Williams 2011 ; Robinson and Morrison 2000 ). Watch Commanders could hold confidential one-to-one meetings with individual firefighters to provide a “safe” environment in which perceived breaches can be discussed (Lester et al. 2007 ). Moreover, senior management should avoid creating any further distance between themselves and their employees because this would give the impression that the employer is less inclined about the relationship with their employees (Coyle-Shapiro and Prazefall 2008 ). It is positive that so many of the interviewees viewed their direct employer (the UKFRS) in a positive light. Further, some organisational stressors could be ameliorated by acting to minimise role overload and improving employees’ perceptions of career progression (Gakovic and Tetrick 2003 ; Xavier and Jepsen 2015 ).

From our interviews, it is clear that the firefighters experienced a range of stressors within and outside of work, which negatively impact on their physical and mental wellbeing. Therefore, strategies should be implemented by the UKFRS to resolve the issues that cause negative outcomes. For example, for incident-related stressors, the UKFRSs can ensure there are sufficient debriefing opportunities following a difficult incident, especially with newer recruits. Another important consideration is what, if any, action can be taken to assist firefighters in creating a better work-home life balance. This might include exploring different shift patterns that could be adopted. Since some stressors are intrinsic to the job, training in mindfulness, which appears to be having success in associated professions (Jha et al. 2017 ; Westphal et al. 2015 ), is another intervention that could be trialed and evaluated.

The aim of the current study was to address a gap in the literature on PC theory by adopting qualitative methods to explore its relevance to the firefighting profession. PC was found to be a valid construct in understanding firefighters’ obligations as their responses reflected multiple facets of PC theory. The current climate of austerity measures in the UK appears to be negatively impacting on firefighters in terms of reducing numbers and placing even higher task demands on those employees remaining. This makes it very difficult for the UKFRS to meet the perceived obligations of their employees providing evidence of PC breach. A range of coping strategies were reported by the firefighters interviewed. The findings have implications for human resource departments within UKFRS trying to manage the impact of funding cuts and they highlight the potential value of the PC as a construct around which such issues can be explored.

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Duran, F., Woodhams, J. & Bishopp, D. An Interview Study of the Experiences of Firefighters in Regard to Psychological Contract and Stressors. Employ Respons Rights J 30 , 203–226 (2018). https://doi.org/10.1007/s10672-018-9314-z

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Cancer risks of firefighters: a systematic review and meta-analysis of secular trends and region-specific differences

Swaantje casjens.

Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany

Thomas Brüning

Dirk taeger, associated data.

The objective of this study was to conduct a systematic review and meta-analysis to evaluate the cancer risks among firefighters in the time course and from different geographical areas.

A PubMed search was performed to identify cohort studies about cancer risk and firefighting presented with standardized incidence ratios (SIRs) or standardized mortality ratios (SMRs). Using random-effect models, meta-relative risk estimates (mSIRs, mSMRs) and 95% confidence intervals (CI) were assessed. Cohort studies with employment starting before 1950 were classified as “old”, studies starting between 1950 and 1970 as “medium”, and later studies as “new”.

The general cancer risk of firefighters was similar to the general population, but mSMR decreased over time (new studies: mSMR = 0.81, 95% CI 0.70–0.92). We observed an increase of mSIR for melanoma of the skin and prostate cancer as well as a decrease of mSIR for stomach cancer with later employment onset. For those cancer sites, we did not observe a secular trend of mSMRs. Regional differences between relative cancer risks were particularly observed for bladder cancer.

Conclusions

Among other things, innovative firefighting techniques and better personal protective equipment have provided a safer and healthier working environment for firefighters over time leading to a reduction of overall cancer incidence and mortality ratios. Increased general preventive medical checkups and possible additional screenings for firefighters might have led to more findings of malignant melanoma of the skin and prostate cancer in the recent past.

Electronic supplementary material

The online version of this article (10.1007/s00420-020-01539-0) contains supplementary material, which is available to authorized users.

Introduction

Firefighting is known to be a high-risk occupation. The International Agency for Research on Cancer (IARC) rated occupational exposure as a firefighter as possibly carcinogenic to humans (Group 2B) (International Agency for Research on Cancer (IARC) 2010 ). Firefighters are exposed to numerous carcinogens during fire suppression, but also at the fire stations. They are exposed to diesel engine exhaust if vehicles are run in closed halls or without appropriate ventilation systems (International Agency for Research on Cancer (IARC) 2010 ; Bott et al. 2017 ; Froines et al. 1987 ). At the fire scene, toxic and carcinogenic substances including metals, chemical substances, minerals, and various gases are released during combustion. The resulting fire smoke is a variable mixture of compounds and its toxicity varies greatly as every burning condition and burning material induces a unique pattern (Golka and Weistenhöfer 2008 ; Guidotti and Clough 1992 ).

Some meta-analyses have examined the extent of cancer risk among firefighters before and did not find higher overall cancer incidence and mortality as expected (International Agency for Research on Cancer (IARC) 2010 ; Jalilian et al. 2019 ; Sritharan et al. 2017 ; Crawford et al. 2017 ; LeMasters et al. 2006 ; Youakim 2006 ; Howe and Burch 1990 ), although a few single studies reported elevated overall cancer risks (Daniels et al. 2014 ; Glass et al. 2016 ; Guidotti 1993 ; Pukkala et al. 2014 ). However, meta-analyses found that firefighters were at increased risk of developing or dying from malignant melanoma of the skin (Jalilian et al. 2019 ; Howe and Burch 1990 ), multiple myeloma (LeMasters et al. 2006 ), mesothelioma (Jalilian et al. 2019 ), digestive (Jalilian et al. 2019 ; LeMasters et al. 2006 ), prostate (Jalilian et al. 2019 ; LeMasters et al. 2006 ; Sritharan et al. 2017 ), testicular (Jalilian et al. 2019 ; LeMasters et al. 2006 ), kidney (Youakim 2006 ), bladder (Jalilian et al. 2019 ), and thyroid cancer (Jalilian et al. 2019 ), as well as non-Hodgkin lymphoma (Jalilian et al. 2019 ; Youakim 2006 ; LeMasters et al. 2006 ).

Findings among these studies have been generally inconsistent. Reasons for this might be the lack of included non-occupational risk factors, missing specification of the exposure, period effects, and country-specific differences. All of these meta-analyses did not consider changes over time of firefighting technology, personal protective equipment (PPE), or used materials in buildings, furniture, or vehicles, which might have led to different cancer risks over the past decades. Combustion and pyrolysis products from newer building materials and furnishings (particularly polymers) are believed to be more toxic than smoke from fires in buildings built before these materials were widely used (Alarie 1985 ). It has been shown in a series of experimental fire tests that the highest pollutant concentrations resulted from the combustion of polymeric materials (Reisen et al. 2014 ). Polymers have been used in large amounts in Europe and North America since the 1950s (Guidotti and Clough 1992 ; Alarie 1985 ; Pedersen et al. 2018 ). However, the other studies showed that the composition of the smoke produced by fires of various kinds was similar (Austin et al. 2001b , c ).

In the past, PPE of firefighters changed tremendously. The use of modern self-contained breathing apparatus (SCBA) started during the 1960s and 1970s (Misner et al. 1987 ), and is commonly used today by municipal firefighters, although they are not worn during the whole firefighting activity especially during overhaul (International Agency for Research on Cancer (IARC) 2010; Austin et al. 2001a ). In the 1980s, modern firefighting helmets like the F1 helmet and advanced fire and heat resistant suits were introduced (Pedersen et al. 2018 ; Hasenmeier 2008 ). The cancer risk in firefighters may also vary between different geographical areas because of probably different exposure patterns depending on work activities and PPE (Howe and Burch 1990 ; Moher et al. 2009 ).

The purpose of this study was to compare cancer risks among professional firefighters from different decades and different geographic areas (North America, Europe, and Korea/Australia/New Zealand) under the assumption that firefighting cancer risks differ in the time course and between geographical areas.

Materials and methods

Search strategy and inclusion criteria.

In March 2019, we searched the PubMed database to identify peer-reviewed original research articles available in English language about cancer risk and firefighting published until 31th December 2018 in accordance with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) (Moher et al. 2009 ). The search string, following the search term from Jalilian et al. ( 2019 ), includes keywords for targeting the occupation (firefighter) and the outcome (cancer incidence or cancer mortality) is presented in Supplemental Table S1. Only articles reporting cohort studies with standardized incidence ratios (SIRs) or standardized mortality ratios (SMRs) regarding the general population as reference or case–control studies were eligible for this meta-analysis. Data extraction was performed by one author (SC) and checked by another (DT). Both authors examined the abstracts independently and agreed on the studies to be included in the meta-analysis.

The PubMed search yielded 601 articles. Additionally, the reference lists of all appropriate articles were reviewed for pertinent studies that may have been missed in the search resulting in 16 additional records. Cohort studies that examine volunteers (Glass et al. 2017 ), WTC-exposed firefighters (Zeig-Owens et al. 2011 ), or veterans (Blair et al. 1985 ) were excluded from the analyses because of possible different exposure patterns, less attended incidents, and the proposed healthy-volunteer effect. Case–control studies were excluded, because only a few estimates for single cancer sites existed. Hence, comparisons between regions or employment start were not feasible. When several articles provided risk measurements for the same study, only those with the broadest scope were included. For this reason, the results of four publications were not included in this meta-analysis (Firth et al. 1996 ; Giles et al. 1993 ; Heyer et al. 1990 ; Rosénstock et al. 1990 ). In total, 25 cohort studies were included in the meta-analysis (Fig.  1 ). We report only on cancer types which have been reported by more than one study and for male professional full-time firefighters. Cancer types were converted from earlier versions of the International Classification of Diseases (ICD) to the tenth revision (ICD-10). If appropriate, we additionally calculated estimates for all ICD-10 codes of a specific site combined, but also present the results for single ICD codes.

PRISMA flowchart of literature search for cancer in firefighters

The meta-relative risk estimates (mRRs) were assessed with inverse-variance random-effects meta-analyses with Paule–Mandel heterogeneity variance estimator τ 2 and presented with the according 95% confidence intervals (CI) (Paule and Mandel 1982 ; Veroniki et al. 2016 ). Greater values of τ 2 depict stronger between-study variances. If τ 2  = 0, the mRRs are equal to the fixed-effects estimates. For the distinction between the mRRs of different estimates, we denote mRRs based on SIRs and SMRs as mSIRs and mSMRs. The percentage of variation across studies resulting from heterogeneity rather than chance were assessed with the I 2 statistic (Higgins and Thompson 2002 ). Heterogeneity testing based on Cochran’s Q . Q is distributed as a Chi-square statistic with k − 1 degrees of freedom ( k describing the number of studies). The hypothesis of homogeneity among studies would be rejected if Q exceeds χ k - 1 α 2 . The potential for publication bias was graphically explored through funnel plots and tested with the modified regression test (Lin and Chu 2018 ). All statistical analyses were undertaken using SAS, version 9.4 (SAS Institute Inc., Cary, NC, USA).

Subgroups reported in this analysis were defined as follows: cohort studies with employment starting before 1950 were classified as “old”, studies starting between 1950 and 1970 were classified as “medium”, and later than 31th December 1970 studies were classified as “new”. Studies located in the United States or Canada were summarized in the North America group. Studies from South Korea, Australia, and New Zealand were combined in the KOR/AUS/NZL group. The third group comprises studies from Europe, mainly from Scandinavia. Overall meta-analyses were only performed for cancer types which have been reported by more than one study. Subgroup analyses were done if data for more than one stratum existed and if cancer types have been reported by more than one study in at least one stratum. mRRs of single cancer types stratified by employment time or region were only presented in the main text if meaningful differences existed. Otherwise, results are presented in supplemental tables.

Overall, 25 articles of cohort studies were included in this meta-analysis of those 56% presenting a cancer mortality (SMR), 28% a cancer incidence outcome (SIR), and 16% both estimates (Table ​ (Table1). 1 ). Reported study populations were from six different countries in Europe, North America, South Korea, Australia, and New Zealand, but were mainly conducted in the United States and Canada (52% of articles). An overview of the extracted estimates from those 25 cohort studies is displayed in Supplemental Table S2.

Characteristics of included cohort studies on firefighting and cancer risk

Tables ​ Tables2 2 and ​ and3, 3 , and Supplemental Table S3 summarize the overall meta-analysis results of cancer risks of male professional firefighters from cohort studies for cancer incidence and mortality. The overall cancer mSIR of firefighters was similar to the general population and did not show a secular trend (Fig.  2 ). For individual cancers, we observed statistically significant elevated mSIR estimates for mesothelioma (mSIR = 1.46, 95% CI 1.01–1.90), bladder cancer (C67–C68 combined: mSIR = 1.14, 95% CI 1.04–1.23; C67: mSIR = 1.18, 95% CI 1.01–1.34), and colon cancer (mSIR = 1.11, 95% CI 1.00–1.21). We did not observe a secular trend for these cancer types. However, increased incidence risks over time exist for malignant melanoma of the skin, overall skin cancer, prostate, and testis cancer. The mSIR for stomach cancer was elevated in firefighters in the earliest employment period starting before 1950 (mSIR = 1.75, 95% CI 1.31–2.19, Supplemental Table S4) and decreases afterwards. In addition, a statistically significant reduced mSIR was observed for trachea and lung cancer in the period of employment starting after 1970. The mSIR of liver and brain cancer among firefighters was slightly lower than expected especially in the time of later employment. Other cancer sites were analyzed by only very few studies or showing no association with start of employment (Supplemental Table S4, Supplemental Fig. S1 and S2).

Meta-relative risk estimates for cancer incidence

Statistically significant results are marked in bold

Study IDs IDs of included studies in this meta-analysis as depicted in Table ​ Table1, 1 , mSIR meta-relative standardized incidence ratios assessed with an inverse-variance random-effects meta-analysis with Paule–Mandel heterogeneity variance estimator τ 2 , CI confidence interval, p value p value of heterogeneity test

Meta-relative risk estimates for cancer mortality

Study IDs IDs of included studies in this meta-analysis as depicted in Table ​ Table1, 1 , mSMR meta-relative standardized mortality ratios assessed with an inverse-variance random-effects meta-analysis with Paule–Mandel heterogeneity variance estimator τ 2 , CI confidence interval, p value p value of heterogeneity test

Secular trends of standardized incidence ratios of selected cancer types presented with 95% confidence intervals

The overall cancer mSMR of firefighters was similar to the general population, but decreased over time (employment start ≤ 1970: mSMR = 1.063, 95% CI 0.9–1.13 versus employment start > 1970: mSMR = 0.81, 95% CI 0.70–0.92), as shown in Fig.  3 . Overall, mSMRs were increased for rectal cancer (C19–C21 combined) and bladder cancer (C67) but not when considering malignant neoplasms of bladder together with other/unspecified urinary organs (C67–C68 combined). The mSMRs for rectal and brain cancer were increased especially in studies with employment starting between 1950 and 1970. Reduced but not always statistically significant mSMRs were observed for stomach, liver, trachea and lung, prostate, and brain cancer in the period of later employment. For stomach, liver, as well as trachea and lung cancer, findings were consistent across study types revealing a decreasing mSMR with later employment. However, the mSIR of prostate cancer increased over time, whereas its mSMR decreased.

Secular trends of standardized mortality ratios of selected cancer types presented with 95% confidence intervals

Table ​ Table4 4 depicts the mSIR and mSMR results for selected cancer types stratified by region. The bladder mSIRs (C67 and C67–C68) were statistically significant in USA/Canada but not in Europe or KOR/AUS/NZL. In KOR/AUS/NZL, the estimates for malignant melanoma of the skin (mSIR = 1.43, 95% CI 1.27–1.58), prostate cancer (mSIR = 1.23, 95% CI 1.11–1.34), and testis cancer (mSIR = 1.47, 95% CI 1.10–1.83) were elevated. The mSIR of pancreas cancer was statistically significant increased only in Europe (mSIR = 1.23, 95% CI 1.01–1.45). In contrast, lung cancer mSIR was reduced in KOR/AUS/NZL (mSIR = 0.83, 95% CI 0.68–0.98). Overall, mSMR were decreased in KOR/AUS/NZL studies (mSMR = 0.78, 95% CI 0.59–0.97) in comparison to studies from North America (mSMR = 1.03, 95% CI 0.94–1.12). In addition to the increased bladder cancer mSIRs in North American studies, we only observed an increased SMR for bladder cancer (C67) but not for cancer of the bladder and other/unspecified urinary organs (C67-C68) in North American studies. The mSMR of pancreas or prostate cancer did not differ between regions, but stomach as well as trachea and lung cancer mSMRs were lowest in studies from KOR/AUS/NZL. Overall, lymphohematopoietic cancer SMR was lower than expected in all studies, but more pronounced in studies from North America. There were no meaningful differences between study regions for other cancer types (Supplemental Table S5). Heterogeneity is present between the studies. Especially studies with higher standard error will tend to report SIR or SMR more extreme for overall cancer (Supplemental Fig. S3).

Meta-analysis results of selected cancer types for cancer incidence and mortality stratified by region

Study IDs IDs of included studies in this meta-analysis as depicted in Table ​ Table1, 1 , mRR meta-relative risk estimates (cancer incidence: standardized incidence ratios; cancer mortality: standardized mortality ratios) assessed with an inverse-variance random-effects meta-analysis with Paule–Mandel heterogeneity variance estimator τ 2 , CI confidence interval, p value p value of heterogeneity test

This is the first meta-analysis exploring region-specific differences and secular trends. High heterogeneity was present in the previous meta-analyses that may be explained by these factors. We included the most recently published cohort studies on cancer risks of male professional firefighters by a systematic literature search to compare cancer risks among firefighters from different decades and different geographic areas.

Period of employment has been investigated as confounder according to cancer risks among firefighters in single-cohort studies before (Guidotti 1993 ; Baris et al. 2001 ; Kullberg et al. 2018 ; Petersen et al. 2018 ; Vena and Fiedler 1987 ), but was not yet subject of a meta-analysis. Here, we observed a decline of the overall cancer mSMR in the employment period greater than 1970. In accordance with a cohort study of Danish firefighters we also found an increased pancreas cancer mSIR when employment started before 1970 (mSIR = 1.22, 95% CI 1.03–1.41 vs. single study SIR = 1.63, 95% CI 1.08–2.48) in comparison to later periods (Petersen et al. 2018 ). An increased mSMR for bladder cancer (C67), especially in earlier employment periods, is in line with some other cohort studies (Baris et al. 2001 ; Guidotti 1993 ; Vena and Fiedler 1987 ). On the other hand, the changing estimates over time for malignant melanoma of the skin, prostate, testis, stomach, and lung cancer in this meta-analysis were not observed before (Baris et al. 2001 ; Kullberg et al. 2018 ; Petersen et al. 2018 ). We saw no elevated overall cancer mSIR in firefighters, so this meta-analysis could not confirm the reported trend of lower overall cancer incidence among firefighters employed in later periods (Kullberg et al. 2018 ). This might be due to the specific characteristic of that cohort study by Kullberg et al.’s finding generally very low SIRs lying outside the funnel plot of this meta-analysis (Supplemental Fig. S3).

Our results for prostate cancer with estimates for mSIR and mSMR, showing in opposed directions over time, are plausible. Prostate cancer is the second most common malignancy in men worldwide and the sixth most leading cause of cancer death (Baade et al. 2009 ). With the advent of Prostate-specific antigen (PSA) testing in the mid-late 1980 in the United States and other Western countries, more prostate cancers are diagnosed (Baade et al. 2009 ). Special screening programs for firefighters and a higher awareness of potential risks as shown in the World Trade Center Health Registry cohort (Yung et al. 2018 ) may result in additional PSA testing and, hence, more diagnosed prostate cancers in comparison to the general population. On the other hand, mortality rates decrease especially in developed countries because of earlier diagnosis due to PSA testing and improved treatment (Baade et al. 2009 ). In this meta-analysis, geographical differences in prostate cancer mSIRs might be an incidental finding, because the KOR/AUS/NZL studies presenting SIRs for prostate cancer examined only firefighters employed after the mid-1970s.

Occupational exposure as a firefighter has been classified as possibly carcinogenic to humans by IARC with strongest evidence not only on the basis of prostate cancer but also because of testicular cancer (International Agency for Research on Cancer (IARC) 2010 ). In accordance with earlier meta-analyses (Jalilian et al. 2019 ; LeMasters et al. 2006 ), we found an elevated mSIR for testicular cancer being more pronounced in studies with a later period of employment. The incidence rate of testicular cancer has increased especially in Western countries since the middle of the twentieth century (Manecksha and Fitzpatrick 2009 ). Because testicular cancer occurs among younger men with high survival, mortality studies are less relevant (Manecksha and Fitzpatrick 2009 ).

In the recent past, general preventive medical checkups lead to higher incidence rates of malignant melanoma of the skin as this is true for prostate cancer (Brunssen et al. 2017 ). Again, special screening programs for firefighters and higher participation rates may result in more diagnosed melanomas in comparison to the general population as we can see in this meta-analysis and as it has been shown before (Jalilian et al. 2019 ; LeMasters et al. 2006 ). However, the increased mSIR has not been accompanied by a corresponding increase in mSMR which is in line with data from the United States (National Cancer Institute 2018 ). We also found higher incidence rates of malignant melanoma of the skin in studies from Australia and New Zealand (mSIR = 1.43, 95% CI 1.27–1.58) in comparison to studies conducted in other countries (mSIR = 1.05, 95% CI 0.62–1.49) which might be rather caused by exposure to strong sunlight than occupational exposure as a firefighter (Leiter and Garbe 2008 ).

Although lung cancer is the leading cause of cancer related deaths worldwide (Youlden et al. 2008 ), earlier meta-analyses did not find any association between firefighting and lung cancer (Jalilian et al. 2019 ; LeMasters et al. 2006 ). Just a recent cohort of US firefighters from San Francisco, Chicago, and Philadelphia reported increased lung cancer morbidity and mortality risks (Daniels et al. 2014 ). In general, the study by Daniels et al. reported higher SIRs and SMRs than the other studies and lying outside the funnel plots (Supplemental Fig. S3). However, the firefighters in the above-mentioned study were older at end of follow-up (mean age 60 years) than in the other studies which might have also contributed to these findings. Furthermore, the rather younger age of firefighters in the later studies might have caused the statistically significant deficit in trachea and lung cancer incidence (mSIR = 0.76, 95% CI 0.62–0.91).

In accordance with the latest meta-analysis, we did not find an overall association of stomach cancer and firefighting (Jalilian et al. 2019 ). However, stomach cancer was more common than expected in studies with a start of employment before 1950 which is in line with a more detailed analysis in Swedish firefighters (Tornling et al. 1994 ). Stomach cancer has been linked to several occupational exposures, such as working in the rubber manufacturing industry, mining industry, and agricultural industry, as well as exposure to crystalline silica, hexavalent chromium, asbestos, lead compounds, and nitrate (Raj et al. 2003 ; Blair and Freeman 2009 ; Lee et al. 2016 ; Welling et al. 2015 ; Cogliano et al. 2011 ). Firefighters could be exposed to those compounds if the fire site holds these materials. Furthermore, “dusty occupations” could be related to stomach cancer (Raj et al. 2003 ) which might also apply to firefighters who get in contact with dust for example during overhaul. However, the numbers were small with 35 observed stomach cancer cases in the strata of the early employment start.

We revealed lower overall and stomach cancer mSMRs in KOR/AUS/NZL than the United States and Canada. However, studies from KOR/AUS/NZL were conducted in later periods of employment with 80% representing a start of employment after 1970 in comparison to 23% of North American studies. Hence, the difference in mSMRs between regions may result from an actual decline of the overall cancer mortality with later period of employment.

Overall, mSIR and mSMR of bladder cancer (C67) were higher than expected. We did not observe any considerable secular trend but again lower estimates in studies from other countries, in comparison to studies from North America. However, just two non-American studies reported bladder cancer mortality risks. Hence, the risk was driven by the USA/Canada studies. In contrast to the incidence studies, the mortality studies are heterogeneous, but, here, we found the highest risk for all cancer entities. Firefighters are exposed to carcinogens associated with combustion, including polycyclic aromatic hydrocarbons, which represent an important risk factor of bladder cancer (International Agency for Research on Cancer (IARC) 2010 ). Possible different exposure patterns depending on work activities and PPE may have caused such findings.

The limitations of the epidemiological data have to be acknowledged as well. Some of the studies examined relatively small populations of firefighters and thus have low statistical power to analyze especially rare cancer types. Additionally, the low number of eligible studies and different published diagnosis codes for cancer types (e.g., kidney cancer coded as C64, C64–C65, or C64–C66) and individually published combination of ICD codes [e.g., brain cancer (C70–C72) together with malignant neoplasm of peripheral nerves of head, face, and neck (C47) (Daniels et al. 2014 )] complicate the analysis and contribute to low number of studies for each cancer type, especially after stratification by employment period and region. Therefore, it cannot be ruled out that risks will change after new studies will be published. Some studies analyzed incidence and mortality over several decades, which lead to uncertainties in the evaluation of trends in diagnosis, differences in exposure, and changes in PPE over time. Furthermore, the length of follow-up might contribute to biased findings. Especially in cohorts of younger firefighters, too short follow-up times might prevent to observe cancers associated with older age. In addition, the reader should have in mind that comparing SIRs or SMRs between groups is difficult if their confounder distributions differ (Checkoway et al. 2004 ). In general, publications and data from other regions are missing, e.g., Southern Europe, Asia, and South and Central America. Finally, smoking habits and other risk factors were not available in these studies.

In contrast to population-based case–control studies, it is unlikely that cohort studies were missed during the literature search which has been recently published in a letter to the editor (Casjens et al. 2019 ). The firefighter’s population of cohort studies is well defined, and this will lead to a better estimation of potential risks and lesser bias. Additionally, instead of the commonly used DerSimonian–Laird estimator, we used in this meta-analysis the estimator proposed by Paule and Mandel being a better alternative to estimate the between-study variance (Veroniki et al. 2016 ).

In this meta-analysis of 25 cohort studies of firefighters, the overall summary relative risk estimates were rather moderate with the exception of bladder cancer mortality. However, our results suggested differences of cancer mSIRs and mSMRs over time and between regions.

There are secular trends and region-specific differences in the relative risks of some cancer sites of male professional firefighters. The risk estimates are rather moderate and mostly declining over time. The introduction of innovative firefighting techniques, safer PPE, better communications, and information systems, as well as changes in the awareness of hazards have provided a safer and healthier working environment for firefighters over time leading to a reduction of overall cancer SIR and SMR. The increase of general preventive medical checkups and possible additional screenings for firefighters might have led to higher rate of diagnosed prostate cancer and malignant melanoma of the skin in the recent past. However, further efforts must be made to make the job as a firefighter even safer.

Below is the link to the electronic supplementary material.

Acknowledgements

Open Access funding provided by Projekt DEAL.

Compliance with ethical standards

Dirk Taeger received speaker honoraria from accident insurance institutions for the industrial and public sectors. All authors declare that they have no conflict of interest.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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