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Gaps in organizational mental health mitigation within the United States Fire Service

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Gaps in organizational mental health mitigation within the United States Fire Service

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Content Gaps in Organizational Mental Health Mitigation Within the United States Fire Service
Dustin L. Zamboni
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2025

© Copyright by Dustin L. Zamboni 2025
All Rights Reserved

The Committee for Dustin L. Zamboni certifies the approval of this Dissertation
Kenneth Yates
Gamaliel Baer
Patricia Tobey, Committee Chair
Rossier School of Education
University of Southern California
2025

iv
Abstract
Since the year 2014, firefighters have taken their own lives at a rate higher than that of line-ofduty deaths. Commonly identified contributors to this tragedy include sleep deprivation, mental
health illnesses such as post-traumatic stress disorder, and a high prevalence of substance abuse.
Firefighter suicide is also likely underreported due to social stigma or a code of silence. With so
many annual deaths, it is important to identify barriers to bringing improved mental health care
to this population. This research was conducted in the Anytown Fire Department (AFD) in
Arizona, which consists of 132 sworn personnel and four fire stations. The purpose of this
research was to understand why the AFD did not have a mental health component aligned with
its health and wellness program. It sought to identify if this was a result of gaps in knowledge,
motivation, or organizational (KMO) barriers. Ten interviews were conducted with AFD staff.
Interviewees were selected to create a representative sample of the department based on length of
service, gender, and ethnicity. The data analysis determined whether the identified KMO
influences were departmental assets or needs. All 10 influences identified were determined to be
needs based on the interviews. The new world Kirkpatrick model was used to design and
evaluate a comprehensive plan that would attempt to address these needs. This study begins to
elucidate one area of a complex challenge facing the fire service today.
Keywords: behavioral health, burnout, compassion fatigue, firefighter, occupational
health, sleep disturbances, PTSD, suicidality

v
Dedication
To the firefighters who have died by suicide. One tragedy is that there are too many to recognize
individually and many more whose cases are buried due to stigma or a code of silence. The
trigger could have been a single, terrible incident or the result of decades of witnessing trauma
and death. The impact these individuals have had on their colleagues, families, and communities
is immeasurable. May they live on in the memories of their loved ones. May those of us left
behind learn from the devastation of their loss.

vi
Acknowledgements
I would have never been able to undertake this journey on my own, let alone complete it.
I would like to thank my parents for their love and support throughout this process and for
providing me with encouragement every step of the way. I am also grateful to my grandfather,
Dr. Joe Garcia, who first instilled in me a respect for higher education and lifelong learning.
Without his patient tutelage, I would never have navigated my way through my first community
college courses. The academic skills he taught me allowed me to enter such a rewarding and
challenging career. I would like to express my heartfelt gratitude to my doctoral committee,
consisting of Dr. Patricia Tobey, Dr. Kenneth Yates, and Dr. Gamaliel Baer. Their incredible
generosity in sharing their time, expertise, and guidance has allowed me to navigate the intricate
journey of writing this dissertation. This experience through the University of Southern
California (USC) has been life-changing. Similarly, my classmates at USC were indispensable
throughout this academic journey. Our discussions in class and small groups brought the theories
we were learning about to life.
I would like to recognize my mentors and colleagues in the fire service, who have
provided me with inspiration and energy to address this specific topic. Their selflessness in the
line of duty encouraged me to shed light on this complex field with the intention of improving it
for future generations. Their tireless dedication to each other and their communities motivates
me as a member of the fire service, and I am proud to be a part of this field. Special thanks to
Chief Tony Pesch and Chief David Bunce for their advice in designing and executing my
research model for this dissertation.
Finally, I would like to thank my wife, Dr. Lily Zamboni-Chang. Her unwavering support
during my studies contributed directly to my success. I am fortunate to have a life partner who

vii
challenges me intellectually and whose questions make me a better writer and researcher. I drew
inspiration from her hard work and persistence in her everyday life. She will be happy to know
that with this body of work complete, we can finally go fishing again.

viii
Table of Contents
Abstract.......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements........................................................................................................................ vi
List of Tables ................................................................................................................................. xi
List of Figures............................................................................................................................... xii
Chapter One: Introduction to the Study ...........................................................................................1
Context and Background of the Problem.............................................................................2
Organizational Goal.............................................................................................................3
Description of Stakeholder Groups......................................................................................3
Stakeholder Performance Goals...........................................................................................4
Stakeholder Group for the Study .........................................................................................5
Purpose of the Project and Research Questions...................................................................6
Importance of the Study.......................................................................................................6
Overview of Theoretical Framework and Methodology .....................................................7
Definitions............................................................................................................................8
Organization of the Dissertation ........................................................................................12
Chapter Two: Review of the Literature .........................................................................................13
Behavioral Health in the Fire Service at the National Level .............................................14
Clark and Estes’s Gap Analysis Framework .....................................................................49
Anytown Fire Department’s Knowledge, Motivation, and Organizational Influences.....49
Conceptual Framework: The Interplay of the HWC’s Knowledge, Motivation, and
Organizational Framework ................................................................................................67
Summary ............................................................................................................................70
Chapter Three: Methodology.........................................................................................................71

ix
Research Questions............................................................................................................71
Overview of Design ...........................................................................................................71
Research Setting.................................................................................................................72
The Researcher...................................................................................................................73
Data Collection ..................................................................................................................74
Credibility and Trustworthiness.........................................................................................77
Ethics..................................................................................................................................78
Summary ............................................................................................................................78
Chapter Four: Results and Findings...............................................................................................80
Participants.........................................................................................................................81
Determination of Assets and Needs...................................................................................82
Results and Findings for Knowledge Causes.....................................................................84
Results and Findings for Motivation Causes .....................................................................90
Results and Findings for Organizational Causes ...............................................................95
Summary ..........................................................................................................................102
Chapter Five: Recommendations and Evaluation........................................................................103
Recommendations to Address Knowledge, Motivation, and Organization Influences...103
Integrated Implementation and Evaluation Plan..............................................................113
Limitations and Delimitations..........................................................................................127
Recommendations for Future Research ...........................................................................129
Conclusion .......................................................................................................................131
References....................................................................................................................................134
Appendix A: High Burnout..........................................................................................................152
Appendix B: Informed Consent for Research..............................................................................154
Appendix C: Interview Protocol ..................................................................................................158

x
Introduction......................................................................................................................158
Conclusion to the Interview: Post-interview Comments.................................................160
Appendix D: Post-workshop Survey ...........................................................................................161
Appendix E: Post-program Evaluation Tool................................................................................162
Appendix F: Delayed Evaluation Tool ........................................................................................164

xi
List of Tables
Table 1: Organizational Mission, Organizational Performance Goal, and Stakeholder Goal 5
Table 2: Firefighter Fatalities in the United States by Year 17
Table 3: Descriptive Statistics of Perceived Barriers 36
Table 4: Affirmative Responses to PTSD Symptoms 41
Table 5: Knowledge Influences, Types, and Assessments 56
Table 6: Motivation Influences 62
Table 7: Organizational Influences 66
Table 8: Interviewee Demographics 82
Table 9: KMO Influences Analyzed 83
Table 10: Knowledge Assets or Needs As Determined by the Data 89
Table 11: Motivation Assets or Needs As Determined by the Data 94
Table 12: Organizational Assets or Needs As Determined by the Data 101
Table 13: The Four Levels 114
Table 14: Outcomes, Metrics, and Methods for External and Internal Outcomes 117
Table 15: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 119
Table 16: Required Drivers to Support Critical Behaviors 120
Table 17: Evaluation of the Components of Learning for the Program 124
Table 18: Components to Measure Reactions to the Program 125
Table A1: High Burnout Outcomes 152
Table E1: Post-program Evaluation Tool 162
Table F1: Delayed Evaluation Tool 164

xii
List of Figures
Figure 1: Intersectionality Chart Between Firefighter Suicide and Lifestyle Factors 15
Figure 2: Firefighter Suicides in the United States by Year 18
Figure 3: Traumatic Events and Stress Factors Among Firefighters With PTSD Symptoms 20
Figure 4: Relationship Between Risk Factors and Burnout Based on the Degree of Compassion
Fatigue 24
Figure 5: Median Drinks per Week for Male and Female Firefighters 29
Figure 6: Survival Curves Comparing Baseline Assessment and Marital Status With Three
Different Classifications 32
Figure 7: Prevalence of Ever Divorce Among Firefighters by Age 34
Figure 8: Conceptual Framework for Influences on Behavioral Health Within the Fire Service 69
Figure 9: The New World Kirkpatrick Model 116

1
Chapter One: Introduction to the Study
Suicide is the 10th leading cause of death in the United States and the second leading
cause for people 15 to 34 years of age (Centers for Disease Control and Prevention, 2019).
Workplace stress has been shown to influence suicides and attempted suicide in both women and
men (Law et al., 2014). Fire personnel work in rigorous conditions and challenging
environments, increasing occupational and psychological stress (Henderson et al., 2016). This
stimulates mental, psychological, and physical defense mechanisms (National Volunteer Fire
Council, 2012). Consequently, fire service personnel report higher rates of suicidal ideations and
attempts (Stanley et al., 2015) compared to the general population (Heyman et al., 2018).
The total number of firefighter suicides is unknown. However, since 2014, firefighters
have taken their own lives at a higher rate than line-of-duty deaths (Fahy et al., 2020; Firefighter
Behavioral Health Alliance, 2022; Heyman et al., 2018). One multi-state study by Vigil et al.
(2020) revealed firefighters die by suicide in a greater proportion than other U.S. occupational
workers. Additional evidence highlights an occupational culture that is reluctant to discuss
feelings and allows traumatic events to manifest over time (National Volunteer Fire Council,
2012). The prevalence of mental health stigma in the fire service can make firefighters reluctant
to seek help (Smith et al., 2018), propagating negative coping methods that may result in
detrimental outcomes (Nock et al., 2011). Anytown Fire Department does not currently have a
behavioral health program to address suicide and other mental health complications resulting
from routine job duties. An analysis of the Arizona Center for Fire Service Excellence
(AZCFSE), the official state training organization for fire departments, reveals no subsidized
behavioral health programs for fire personnel nor any courses structured to mitigate fire service
occupational stressors.

2
Context and Background of the Problem
The Health and Wellness Committee (HWC) is an internal component of the Anytown
Fire Department (AFD; a pseudonym), located in Maricopa County, Arizona. Created in 2008,
the HWC was established to facilitate fitness-oriented programs to reduce cardiovascular disease
rates within the AFD. The nature of HWC is to analyze mortality causes in the fire service and
develop initiatives to promote a health-based work environment.
Anytown Fire Department is a career municipal fire department with four fire stations. As
an all-risk/full-service public safety organization, AFD services include fire prevention,
advanced life support response, fire suppression, rescue, technical rescue, code enforcement,
public education, and community partnerships. In 2020, AFD responded to approximately 6,000
calls for service, with 132 sworn fire personnel serving roughly 53,600 acres of jurisdiction. This
includes 19,000 acres of natural preserve. The community is predominately rural, with large
tracts of agricultural and riparian areas separated by state transportation thoroughfares. A
commercial corridor delineates the community’s western border, comprising over 25 million
square feet of commercial property.
The HWC is a voluntary group composed of 12 career fire personnel, a peer fitness
instructor group, and a crisis intervention team. A battalion chief heads the HWC. Captains,
engineers, and firefighters complete the chain of command. Cardiovascular disease programs,
cancer awareness initiatives, and injury prevention strategies constitute the agenda of the HWC.
The HWC contains neither behavioral health processes to reduce suicide and suicidal ideation
among firefighters nor mental health preparedness strategies. Regardless of growing behavioral
health awareness, suicide, post-traumatic stress, burnout, and substance abuse continue to
proliferate throughout the fire service (International Association of Firefighters, 2021).

3
Organizational Goal
The goal of HWC is to improve the health of fire personnel. One initiative toward that
overarching goal is the plan that by 2026, 100% of AFD sworn fire personnel would receive
behavioral health evaluations by a licensed psychologist as part of their annual physicals. To
accomplish this, AFD would consult with their contracted healthcare provider to include a
mental health assessment simultaneously with the annual physical evaluations. Doctor-patient
confidentiality laws would keep professional consultations private, eliminating the stigma
associated with those who speak up about their issues. Taking part in their condition’s mutual
decision-making requires effective communication between doctor and patient (Matusitz &
Spear, 2014). By 2026, a licensed psychologist would provide 100% of recruits a week of mental
health awareness in their fire academy to establish positive pathways to mitigate the stress of
fires, abuse, suicides, shootings, stabbings, car accidents, and other distressing events of
customary job duties (Chamberlin, 2019). Personnel records will track the completion of mental
health assessments and will be stored in locked, secure areas in compliance with the Americans
with Disabilities Act, Health Insurance Portability and Accountability Act, and Genetic
Information Nondiscrimination Act.
Description of Stakeholder Groups
The stakeholders for this study include groups both inside and outside of AFD. The
groups within AFD include HWC, the office of the fire chief (OFC), and the fire marshal’s
office. The external stakeholder is the contracted medical provider (CMP) for AFD.
The HWC is the branch within AFD responsible for physical fitness and occupational
standards related to health and wellness and recommends best practices to the fire chief for
policy considerations. Associates of HWC can introduce stress management and behavioral

4
health programs as they intertwine with nutrition and fitness, in line with the International
Association of Firefighters (IAFF) and International Association of Fire Chiefs (IAFC) Wellness
Fitness Initiative recommendations for wellness programs. The Office of the Fire Marshal
provides training in professional development and is responsible for bringing in outside training
to meet the department’s needs. If a new training curriculum is explored, the fire marshal’s office
will work with the OFC to secure facilities and coordinate instructors. The OFC is the final
authority to approve new policies, procedures, and curricula or changes to existing ones.
Additionally, the OFC has the duty to organize, direct, and plan all departmental operations to
align with the organization’s mission and value statements.
The CMP is the organization responsible for AFD’s annual health assessments that
include in-depth cardiac, cancer, and metabolic wellness programs to identify early risk factors
and prevent late-stage disease. The CMP conducts the National Fire Protection Association
(NFPA) 1582 medical exams, Occupational Safety and Health Administration (OSHA) medical
exams, and primary care services. Primary care services include cancer biomarker testing,
calcium scoring, respiratory function tests, functional movement screening, blood tests, and
hearing and vision assessments.
Stakeholder Performance Goals
Table 1 shows AFD’s mission and performance goals. It also includes the goals of the
four primary stakeholders.

5
Table 1
Organizational Mission, Organizational Performance Goal, and Stakeholder Goal
Organizational mission
Maintain a high state of readiness to mitigate all types of fire, medical emergencies, and threat
of potential disasters while ensuring the safety of our personnel and the prevention of
human injuries.
Organizational performance goal
By 2026, 100% of AFD sworn personnel will receive an annual behavioral health evaluation
by a medical professional.
Health and wellness
committee
Fire marshal’s office Contracted medical
provider
Office of the fire
chief
By 2026, HWC will
pilot a behavioral
health program to
provide training
and onsite visits by
a licensed mental
health professional.
HWC will
incorporate a week
of mental health
awareness for all
recruits.
By 2026, the fire
marshal’s office
will collaborate
with HWC to
facilitate training
for veteran
personnel and
immerse the
behavioral health
program into the
recruit academy.
By 2026, the CMP
will provide a
behavioral health
evaluation from a
licensed medical
professional as a
component of
annual firefighter
physical exams
outlined in NFPA
1582.
By 2026, the OFC
will have supported
and approved the
HWC behavioral
health program and
initial and future
funding
requirements.
Stakeholder Group for the Study
The HWC is responsible for designing and implementing new health initiatives for the
AFD, including behavioral health programs currently omitted from department policy. This
group is the focus of the study because it facilitates program execution and influences the
organization’s ability to assess and evaluate the mental health of fire personnel. It is important to
emphasize that routine job duties are responsible for firefighters’ mental health deterioration and
not just catastrophic events, putting all firefighters at risk. Behavioral health programs are

6
important to adopt because the stigma regarding mental health in the fire service can make
firefighters reluctant to seek help.
Purpose of the Project and Research Questions
The purpose of the study was to conduct a gap analysis about knowledge, motivation, and
organizational provisions essential to achieving the stakeholder goal of conceptualizing and
implementing a behavioral health program. The stakeholder goal aligns with the organizational
goal of 100% AFD sworn personnel receiving behavioral health evaluations as part of their
annual medical exams. A comprehensive gap analysis would include all four stakeholder groups
described previously. However, the implementation and evaluation of a behavioral health
program would be the responsibility of HWC; therefore, they are the stakeholders of focus for
the study. The exploration began by identifying suboptimal behavioral health practices and
determining what variables can be systemically incorporated to achieve the desired results. The
following questions guided this study:
1. How do HWC describe the needs of a behavioral health program with AFD?
2. What are the key organizational barriers to the implementation of a behavioral health
program?
3. What strategies can be used to address the assessed needs of AFD concerning mental
health mitigation?
Importance of the Study
Addressing mental health is of growing importance in the United States (Case & Deaton,
2015), especially as suicide rises as a major cause of death (Centers for Disease Control and
Prevention, 2019). Firefighter suicides have been improperly measured in the past, but with them
exceeding line-of-duty deaths, there is indirect evidence that it is a growing problem (Heyman et

7
al., 2018). The fire service is inherently traditional and hierarchal in its culture (U.S. Fire
Administration, 2022). As a result, adaptive solutions incorporating changes in response and
behavior by the firefighters must come from the highest levels of leadership in fire departments
around the country. Promoting adaptive coping to trauma is crucial to reducing psychological
distress and suicidal behaviors in the fire service (Gulliver et al., 2019). However, coping will
require changes in selection, training, screening, and operations in any department that wishes to
effect positive change.
Behavioral health issues like obesity, sleep deprivation, substance abuse, suicide,
depression, post-traumatic stress disorder (PTSD), burnout, and compassion fatigue are fairly
common among firefighters (Berger et al., 2012; Carey et al., 2011; Gist et al., 2011; Haddock et
al., 2015; Soteriades et al., 2008; Wieclaw et al., 2006). Behavioral health programs are designed
to embrace new treatment models to break mental health stigma in fire departments (Raney,
2019). Anytown Fire Department is responsible for treating mental health with the same
significance as physical health, providing access to critical resources for personnel to manage
and overcome preexisting and current work-related problems (National Volunteer Fire Council
[NVFC], 2021). Failure to embrace a behavioral health program will eliminate internal pathways
to recovery and exacerbate existing issues into further manifestations.
Overview of Theoretical Framework and Methodology
As the study’s research framework, I used Clark and Estes’s (2008) gap analysis, a
research-based approach to identifying human causes of performance gaps between current
organizational results and desired outcomes. Gaps in knowledge, motivation, and organizational
factors were analyzed through existing literature, anecdotal observations, and tacit knowledge. I
conducted a formative assessment to develop strategies to aid AFD in accomplishing its goals

8
while reflecting its values. Research recommendations were validated through descriptive
methods, including surveys, interviews, literary reviews, and document inquiry.
This study utilized a qualitative approach to gain an in-depth understanding of behaviors
within the AFD. The research emphasized open-ended interviews to explore the perspectives,
motivations, and emotions of fire personnel, which may uncover underlying means, patterns, and
relationships that cannot be quantified. Qualitative research encompasses naturistic inquiry to
facilitate rich narrative descriptions by uncovering themes and patterns from construct case
studies (Patton, 2015). Descriptive approaches and surveys systematically describe the
characteristics and facts of a specific phenomenon and the relationship between such
phenomenon and events (Merriam & Tisdell, 2016). Interviews focused on comprehending the
knowledge, motivation, and organizational factors that previously existed and those that may
need to be adopted by HWC to develop and disseminate a robust behavioral health program for
the AFD. This exploratory sequential design illustrates there is not a singular prescriptive
approach to mental health mitigation, and this research was interested in why AFD did not
allocate resources to behavioral program development.
Definitions
To clearly understand the terminology used by AFD, definitions and acronyms for terms
that are utilized throughout this study are listed below:
Americans with Disabilities Act of 1990: A civil rights law that prohibits discrimination
based on disability. In addition, the law requires employers to provide reasonable
accommodations to employees with disabilities and imposes accessibility requirements on public
accommodations. The disabilities covered under the act include both mental and physical
conditions (U.S. Department of Labor, n.d.).

9
Anytown Fire Department: The fire department discussed in the study. The department’s
true name is disguised to protect the privacy of those interviewed.
Arizona Center for Fire Service Excellence: Established in 2010, the AZCFSE is
responsible for the day-to-day administration of fire service training and Arizona firefighter
certification processes for the state of Arizona (AZCFSE, 2019).
Centers for Disease Control and Prevention (CDC): A governmental service organization
formed in 1946 with the primary goal of protecting public health and safety through the control
and prevention of disease, injury, and disability in the United States and worldwide. Some areas
of focus include infectious disease, occupational safety and health, injury prevention, and
chronic diseases (CDC, 2019).
Crisis intervention team: A community partnership between law enforcement, mental
health providers, emergency services, and individuals living with mental illness. The purpose of
these programs is to improve community responses to mental health crises (NAMI, n.d.).
Contracted medical provider: A medical provider that has an agreement with a health
plan to accept patients and provide treatment at a previously agreed-upon rate for payment
(Business Benefits Insurance Solutions, n.d.).
Emergency medical technician (EMT): A medical professional trained in basic life
support who provides out-of-hospital emergency medical care and transportation for patients
requiring immediate medical assistance, most commonly on ambulances (WebMD, 2023).
Firefighter Behavioral Health Alliance (FBHA): Established in 2011 by retired captain
and licensed counselor Jeff Dill. The organization’s primary goal is to provide behavioral health
workshops to fire departments and emergency medical services (EMS) organizations, focusing

10
on behavioral health awareness with a strong drive toward suicide prevention. The organization
also provides resources to firefighters and their families (FBHA, 2022).
Genetic Information Nondiscrimination Act: A 2008 act of Congress that prohibits
discrimination based on genetic information with respect to health insurance and employment
(U.S. Equal Employment Opportunity Commission, n.d.).
Health Insurance Portability and Accountability Act: A 1996 act of Congress that
generally prohibits healthcare providers and businesses from disclosing protected information to
anyone other than a patient and the patient’s authorized representatives without their consent
(U.S. Department of Health and Human Services, n.d.).
Health and Wellness Committee: A committee within AFD that seeks to plan, promote,
and implement wellness initiatives for employees to improve their mental and physical health
(IAFF, 2021).
International Association of Fire Chiefs: An organization representing the leadership of
firefighters and emergency responders worldwide. Its purpose is to provide guidance to current
and future leaders in the fire service through vision, information, education, services, and
representation (IAFC, 2023).
International Association of Firefighters: A labor union representing full-time career
firefighters and EMS personnel in the United States and Canada. The union has advocated for
better wages, working conditions, and improved safety for members (IAFF, n.d.).
Line-of-duty death (LODD): A death in the fire or police service while the individual is
on duty (IAFF, 2021).
National Fallen Firefighters Foundation (NFFF): An organization created by the U.S.
Congress to lead a nationwide effort to remember America’s fallen firefighters. The non-profit

11
foundation also has programs to assist surviving families and co-workers of the deceased (NFFF,
2023).
National Fire Protection Association: A U.S.-based international non-profit organization
whose goal is to eliminate death, injury, property, and economic loss due to fire, electrical, and
related hazards (NFPA, 2021a).
National Volunteer Fire Council: A non-profit membership association representing the
interests of the volunteer fire, EMS, and rescue services. The council provides information
regarding legislation, standards, and regulatory issues (NVFC, 2023).
Peer fitness instructor: A firefighter with a certification demonstrating the knowledge
and skills required to design and implement fitness programs that will improve the wellness and
fitness of their fire departments (IAFF, 2021a).
Occupational Safety and Health Administration: A large regulatory agency within the
U.S. Department of Labor. Its mission is to ensure safe and healthy working conditions by
setting and enforcing standards and providing training, outreach, education, and assistance
(OSHA, 2023)
Post-traumatic stress disorder: A mental and behavioral disorder that can develop
following a traumatic event. Symptoms may include disturbing thoughts, dreams related to the
event, and distress in response to triggering cues. Complications include suicide as well as other
physical disorders (Mayo Clinic, 2024).
Wellness Fitness Initiative: An initiative by the IAFF in cooperation with the IAFC. The
purpose is to create a comprehensive wellness program that emphasizes physical, mental, and
emotional well-being to all personnel, from recruits to retirees (IAFF & IAFC, 2018).

12
Organization of the Dissertation
Five chapters were compiled for this study. This first chapter provided key concepts
regarding the problem of practice examined and AFD’s organizational structure. It explores the
AFD’s vision, goals, mission, and stakeholders, in addition to suboptimal concepts creating the
gap from current to desired performance results. Chapter Two provides a review of preexisting
literature encompassing the totality of the study. It discusses international statistics on firefighter
suicides and correlating mental health symptoms and behavioral health program initiatives at the
national (macro), state, and local (micro) levels. Chapter Three dissects the anticipated resources
for this study, including methodological nuances of data collection, analysis, and participant
selection. In Chapter Four, the data and findings are assessed and analyzed. Subsequently,
Chapter Five provides recommendations for closing performance gaps while utilizing data and
literature to design and implement a behavioral health plan at AFD.

13
Chapter Two: Review of the Literature
Suicide is a concern to fire service personnel due to the chronic frequency of suicidal
ideations and behaviors stemming from routine job duties (Pennington et al., 2021). The NFFF
(2014) reported that firefighters are three times more likely to perish by suicide than in the line
of duty. The Firefighter Behavioral Health Alliance (FBHA) statistics reveal suicide has
contributed to more firefighter deaths for the last 7 consecutive years compared to the NFPA’s
line-of-duty death reports. Subsequently, the ratio of suicide to line-of-duty deaths has reached
2:1 in 6 out of the last 7 years (Fahy et al., 2020; FBHA, 2022). A report by the NFPA revealed
that many fire departments in densely populated areas have health and wellness programs that
address cardiovascular health, cancer, obesity, sleep deprivation, and development of fitness
programs (NFPA, 2021b). However, in these departments, suicide rates have not decreased.
Currently, the NFPA 1500 standard formulates a behavioral health model designed to operate
within health and wellness programs (NFPA, 2016). In Arizona, no behavioral health training is
available through the AZCFSE according to their course curriculum (AZCFSE, 2019). The
intention of this research was to understand why AFD does not have a comprehensive behavioral
health program and what is needed to mitigate behavioral health issues if no program
development is desired.
It is imperative to delineate between firefighters’ occupational hazards and the overall
lifestyle factors that occur outside the workplace. While these two areas can both interact and
contribute to a firefighter’s overall health, this dissertation focuses on the occupational hazards
that departments and professional organizations can influence or control. Examples of
occupational hazards include traumatic experiences on the job, exposure to dangerous chemicals,
work injury, and sleep deprivation due to overnight duties. Conversely, lifestyle factors include

14
decisions about diet, exercise, and alcohol or substance abuse. This research focuses on
occupational hazards over lifestyle choices because occupational safety and risk reduction is my
personal interest and subject matter expertise.
This chapter will encompass an inquiry into pertinent research and establish a conceptual
framework model that guides data collection. The review of the literature will examine
firefighter suicide statistics, national and state trends, fire service behavioral health programs,
and conventional research on PTSD, compassion fatigue, burnout, sleep deprivation, and
substance abuse. Behavioral health initiatives and protocols from national, state, and local
jurisdictions will also be explored. Theoretical literature illustrating knowledge, motivation, and
organizational relevancy will be reviewed, which will lead to influencing variables related to
AFD’s behavioral health program development. After the literature review, this chapter
examines Clark and Estes’s (2008) gap analysis conceptual framework utilizing knowledge,
motivational, and organizational proclivities on AFD’s potentiality to engineer and enact a
behavioral health curriculum.
Behavioral Health in the Fire Service at the National Level
This section is a summary of literature within the fire service at a national stratum. The
following segment starts by analyzing the national suicide statistics in the fire service and
contributing factors as documented by NFPA (2021c). The NFPA identifies sleep deprivation,
PTSD, burnout, compassion fatigue, substance abuse, cultural stigmas, and lack of effective
resources as factors contributing to firefighter suicide. Figure 1 displays prior research on
lifestyle factors of these issues. This section then continues with a summary of strategies and
proposals that exist nationwide within government and non-governmental fire service
organizations.

15
Figure 1
Intersectionality Chart Between Firefighter Suicide and Lifestyle Factors
Firefighter Behavioral Health Trends
The NFPA is a global non-profit organization dedicated to eliminating death and injury
due to fire and related hazards (NFPA, 2021a). Since 1977, it has collected annual data on all onduty firefighter fatalities. Because most firefighter suicides occur off duty, NFPA numbers do
not accurately measure the severity of the problem. The exact number of firefighter suicides is
Firefighter
Suicides
Sleep
deprivation
PTSD,
depression,
anxiety
Compassion
fatigue
Burnout
Substance
abuse
Cultural
stigma
Stressors
Lack of
effective
resources

16
unknown, as there is no formal tracking system at the national level (Antonellis & Thompson,
2012), further complicating data collection. The FBHA is a non-profit organization that collects
data on firefighter and EMS suicide, including categorizations by age, method, years of service,
and state. The following section describes historical and current trends of suicide in the fire
service.
Suicide
The impact of routine job duties on firefighter mental health has evolved over the last 2
decades. Fire departments are witnessing a shift in the threat to firefighter health, as suicide
surpasses line-of-duty deaths. According to FBHA statistics, 136 firefighter/EMT suicides
occurred from 1880 to 1999, while 1,642 have been documented since 2000 (FBHA, 2022).
Since 2012, there have been 1,284 firefighter/EMT suicides (FBHA, 2022), compared to 668
line-of-duty deaths (NFPA, 2021c). Table 2 categorizes the total firefighter deaths in the United
States for the years 2012 to 2020, regardless of classification. Figure 2 presents firefighter/EMT
suicides for a similar period, regardless of method, age, or classification.

17
Table 2
Firefighter Fatalities in the United States by Year
Year Total Career Volunteer Non-municipal*
2012 64 23 30 11
2013 98 26 41 31
2014 64 23 34 7
2015 68 24 32 12
2016 69 19 39 11
2017 60 21 32 7
2018 65 25 35 5
2019 48 20 25 3
2020 62 23 27 12
Note. From Firefighter Fatalities in the US in 2020 by National Fire Protection Association,
2021c. (https://www.usfa.fema.gov/downloads/pdf/publications/firefighter-fatalities-2020.pdf).
In the public domain.
*Excluding COVID-related deaths.

18
Figure 2
Firefighter Suicides in the United States by Year
Note. From FF, EMS, & CS Suicide Deaths by Year & Type by Firefighter Behavioral Health
Alliance, 2022. (https://www.ffbha.org/ff-ems-suicide-deaths-by-year-type/). In the public
domain.
Post-traumatic Stress Disorder
Firefighters experience job stressors that can lead to mental health conditions like PTSD,
which ensues after a consequential event and can inhibit a person’s ability to manage stress. The
traumatic experiences firefighters face may increase their risk of PTSD to higher than for
workers in other career fields (U.S. Fire Administration [USFA], 2022). A study published in the
Journal of Occupational Health Psychology revealed fire personnel acquire PTSD at a
91
79
130
156 155
126
118
147
129
101
52
0
20
40
60
80
100
120
140
160
180
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Firefighter Suicides

19
comparable frequency to U.S. military personnel returning from combat (Corneil et al., 2016).
The report concludes that roughly 20% of firefighters and paramedics meet or exceed the
conditions for PTSD during their careers, compared to a 6.8% probability for the general
population. This suggests a strong relationship between rescue work and PTSD. A 2016 study in
Occupational Medicine of 3,289 firefighters found that 13% of the participants met PTSD
criteria. Of those individuals, the most common traumatic events they related involved the death
or rescue of a child (39%), followed by dealing with a mass fatality incident (28%). Figure 3
represents the stress factors of rescue work that were identified in the PTSD population among
firefighters (Katsavouni et al., 2016).

20
Figure 3
Traumatic Events and Stress Factors Among Firefighters With PTSD Symptoms
Note. Adapted from “The Relationship Between Burnout, PTSD Symptoms and Injuries in
Firefighters,” by F. Katsavouni, E. Bebetsos, P. Malliou, & A. Beneka, 2016, Occupational
Medicine, 66(1), 32–37. (https://doi.org/10.1093/occmed/kqv144). Copyright 2015 by
F. Katsavouni, E. Bebetsos, P. Malliou, and A. Beneka.
Firefighters, police officers, and military personnel are tasked with emergency response
and operate within similar work environments. There is sequential exposure to traumatic events,
resulting in an increased risk for PTSD. A meta-analysis from the International Journal of
Environmental Research and Public Health (Obuobi-Donkor et al., 2022) estimated that up to
35% of global first responders experience behavioral health disorders. For ambulance personnel,
the study found rates of 27% for psychological distress, 15% for depression, 15% for anxiety,
•Death or rescue of a child (39%)
•Dealing with a mass fatality incident (28%)
•Dealing with mutilated victims (13%)
•Rescue families in car accidents (13%)
•Rescue victims from crashed buses/trains (7%)
Traumatic events
•Health condition (37%)
•Prior personal trauma (24%)
•Depression about the responsibility for the victim’s quality of life (22%)
•Individual family problems (9%)
•Individual financial problems (8%)
Internal stress factors
•Pressure on behalf of observers, TV, etc. (71%)
•Insufficient technique (9%)
•Lack of personnel and equipment (8%)
•Additional workload (6%)
•Institutional policies and practices (6%)
External stress factors

21
and 11% for PTSD. The occurrence of PTSD in veterans who experienced combat was estimated
to be between 10% and 15%, compared to firefighter rates that ranged between 6.5% to 37%
(Del Ben et al., 2006). Having separate categories for ambulance and fire personnel may not
reflect the totality of PTSD, as 63% of U.S. fire departments provide EMS support (USFA,
2022).
Firefighter Burnout
Firefighters encounter some of the most hazardous working conditions of any workforce,
including physically and psychologically taxing demands and tasks (DeJoy et al., 2017). The fact
that 49% of surveyed firefighters reported high levels of physical and emotional burnout
demonstrates that burnout is a widespread problem (Wolkow et al., 2019), although this may also
be a result of lifestyle choices outside of the profession. Firefighter burnout is associated with
riskier behaviors related to on-the-job safety and higher risks of injury (Smith et al., 2018). Thus,
innovative leadership in local departments and at the national level is needed to address the
problem of burnout in firefighters and mitigate its negative effects.
Burnout is often a byproduct of exhaustion, depersonalization, and cynicism
(ten Brummelhuis et al., 2011), which collectively lead to defiance of departmental norms and
expectations and create diminishing safety outcomes (Smith et al., 2018). Wolkow et al. (2019)
published one of the largest studies ever undertaken to address sleep disturbances and burnout in
the fire service. The authors measured burnout in firefighters and examined other factors that
potentially correlated with burnout. The study concluded that sleep disorders, insomnia, current
mental health diagnoses, and disrupted sleep all correlated with specific domains measured by
the Maslach Burnout Inventory, which is included in Appendix A (Wolkow et al., 2019). These
negative correlations point to potential solutions and generate several technical-adaptive and

22
adaptive questions for how fire departments can intervene to mitigate or prevent burnout: Can an
individual firefighter experiencing burnout make necessary changes alone, or can the problem of
burnout only be solved through group efforts? What patterns of behaviors related to burnout can
be observed by members of a fire department, and what behaviors cannot be readily seen? What
values, behaviors, or beliefs may have to change to address burnout? What departmental changes
do firefighters perceive would aid in lessening their burnout? What changes have been effective
for other fire departments experiencing the problem of burnout?
Burnout is a conditional response to ongoing stress, where the body’s energy is depleted
over time (Shirom, 1989). Vaulerin et al. (2016) conducted a study of 220 French firefighters to
uncover associations between the big five personality traits and burnout and how this
relationship affected achievement goals. The findings yielded a positive correlation between
neuroticism and the three dimensions of burnout through indirect and direct mastery avoidance
goals. Burnout has been explained within the origins of conservation of resource theory, which
emphasizes cognitive, emotional, and physical energy expenditure (Monnier et al., 2000). A core
principle of the theory infers that motivation to receive, retain, and protect energy resources is an
innate ability. This ability gets depleted in firefighters through emotional exhaustion and
depersonalization by occupational stressors (Hobfoll et al., 2001). Fire service leaders need to
understand theoretical perspectives and incorporate the theories into implementation strategies
that limit the effect of psychological stressors on fire personnel.
Compassion Fatigue
Compassion fatigue is known as the emotional, mental, and physical state experienced by
professionals who assist others in distress (Grant et al., 2019). Figley (2002) identified
compassion fatigue as the cost of caring for those in careers that routinely treat and provide care

23
for those suffering from pain and traumatic events. Compassion fatigue is a threat to firefighters’
quality of life that can manifest in toxic work and home environments (Bouchard, 2019).
Current research estimates that up to 50% of career firefighters caring for traumatized patients
may be at high risk for developing compassion fatigue (Zeidner et al., 2013). Occupational
exposures may account for many of these firefighters, but lifestyle factors and even religious
beliefs may also contribute. Kim et al. (2020) conducted a study of 371 firefighters from 10
different fire departments to determine the relationship between compassion fatigue, burnout,
and occupational environment. The study utilized the Maslach Burnout Inventory, Compassion
Fatigue Self-test, and the Working Environment Inventory as the basis for their questionnaires.
The findings revealed a significant correlation between a rise in compassion fatigue and a
reciprocal effect in burnout and environmental risk factors (Figure 4). A separate study
conducted by Sun et al. (2016) consisted of administering the Chinese version of the Compassion
Fatigue Short Scale, which uses a 13-item questionnaire to rank the frequency of each item on a
10-point Likert scale, to 388 Shanghai firefighters. The results confirmed a correlation between
secondary trauma and burnout associated with compassion fatigue. These findings suggest that
firefighters’ mental health needs to be protected due to the fact that substantial working pressure
coupled with compounding emotional stress can affect their ability to treat and care for others.

24
Figure 4
Relationship Between Risk Factors and Burnout Based on the Degree of Compassion Fatigue
Note. From “The Moderating Effect of Compassion Fatigue in the Relationship Between
Firefighters’ Burnout and Risk Factors in Working Environment,” by R Kim., J. H. Ha, & J. Jue,
2020, Journal of Risk Research, 23(11), 1491–1503.
(https://doi.org/10.1080/13669877.2020.1738529). Copyright 2020 by the authors.
Sleep Deprivation
Firefighters often work long shifts, sometimes 24 hours or more, and are frequently
called upon to respond to emergencies at all hours of the day and night. This irregular schedule
can disrupt standard sleep patterns and lead to chronic sleep deprivation. Sleep deprivation can
have severe consequences for firefighters, as it may impair cognitive function, reduce reaction
times, and degrade the ability to make quick, accurate decisions. This is concerning given the
high-pressure situations firefighters often find themselves in. Additionally, sleep deprivation can

25
weaken the immune system, making firefighters more susceptible to illness. It can also increase
the risk of cardiovascular disease, which is already a leading cause of death among firefighters
(Luyster et al., 2012).
Sleep is a biological necessity (Ramar et al., 2021). It allows the body to rest, repair, and
function from the cellular to systemic levels. Sleep plays a role in immune health, learning,
creativity, and mood (Walker, 2017). As one would expect, inadequate amounts of sleep can be
detrimental in all these areas and more. The American Academy of Sleep Medicine recommends
that the average adult should regularly sleep 7 or more hours per night to promote optimal health
(Watson et al., 2015). However, sleep disturbances among full-time professional firefighters are
par for the course. Unlike most workers who work 12 hours or less, a firefighter’s shift typically
lasts 24 to 72 hours. Occupations that require overnight, rotating, or extended hours have been
associated with an increased prevalence of cardiometabolic and mental health disorders (Pack &
Pien, 2011). Firefighting is no exception. Activity and emergency response are required both
during the day and at night. Shifts can be erratic and filled with multiple interruptions to sleep
due to stressful and/or dangerous situations. These conditions, along with off-duty time
commitments, easily result in inconsistent sleep schedules. Inadequate or inconsistent sleep may
increase fire fighters’ risk of several mental and physical disorders associated with poor sleep:
weight gain and obesity, diabetes, hypertension, heart disease and stroke, depression, and
increased risk of death (Watson et al., 2015).
In a study of 303 firefighters in Brazil, researchers ascertained that 51% of the study
population experienced sleep disturbances in their daily life (Barros et al., 2012). Psychological
distress and psychosomatic disturbances were significantly associated with sleep disturbances
among this population. In addition, suicidal ideation and alcohol abuse were positively correlated

26
with sleep disturbances, although this was not statistically significant. These findings suggest
that the interplay between sleep, mental health, and alcohol abuse is complex. Interestingly,
length of time on the job was found to be a protective factor, suggestive of a healthy worker
effect. This model proposes that certain workers can utilize coping mechanisms to deal with the
adverse conditions and most harmful exposures, reducing the negative consequences of the
profession. On the other hand, workers who do not adapt well to the job tend to leave it for a
better-fitting role. This self-selection creates an older survivor group, who is better suited to cope
with the demands of a specific field (Parkes, 1999). In the field of firefighting, this would
correspond to a self-selection of those who can adapt to the disruptive lifestyle and sleep patterns
created by the nature of shift work.
Specific sleep disorders can exacerbate the poor quality of sleep firefighters experience in
the setting of sleep disturbances related to their occupation. One study of 6,933 firefighters in the
United States found that 37% of firefighters screened positive for obstructive sleep apnea, 6% for
insomnia, 9.1% for shift work disorder, and 3.4% for restless leg syndrome. Overall, 80% of
these conditions were undiagnosed and untreated. Compared to firefighters who had negative
screenings for all these disorders, those with one or more positive screenings were more likely to
report a motor vehicle crash and falling asleep while driving. They were also more likely to
report a history of cardiovascular disease, depression, anxiety, and poor health status (Barger et
al., 2015).
Another study out of Stanford University sought to examine sleep as an independent risk
factor for late-life suicide (Bernert et al., 2014). This was a longitudinal case-control cohort
study of suicides among a community sample of older adults. Four hundred control subjects were
matched (based on age, sex, and study site) to 20 individuals who had died by suicide. Using a

27
primary measure of the Sleep Quality Index, the researchers found that poor sleep quality at
baseline was significantly associated with an increased risk for suicide with an odds ratio of 1.39
(p < 0.001) by the end of the 10-year follow-up period. Two specific items were associated with
an elevated risk for suicide: difficulty falling asleep (odds ratio of 2.24) and non-restorative sleep
(odds ratio of 2.17). Even when the cohorts were controlled for depressive symptoms, baseline
self-reported sleep quality was associated with an increased risk of suicide. They concluded that
sleep disturbances appear to confer considerable risk, independent of depression, for suicidal
behaviors.
A U.S. study in 2016 sought to examine the interaction between sleep disturbances and
depression, the main contributor to suicide (M. A. Hom et al., 2016). The researchers examined
emotional dysregulation as an explanatory factor in association with insomnia symptoms,
nightmares, and depressive symptoms among current and retired firefighters. Based on the
analysis of a survey of 880 individuals, the evidence supported their hypothesis that insomnia
and nightmares may influence depression symptoms through explicit emotion regulation
difficulties. Lack of access to emotion regulation strategies may, in part, explain the link between
sleep disturbances and depression among firefighters. In addition, disturbed sleep potentially
impairs the ability to access and leverage emotion regulation strategies effectively. This confers a
risk of negative affect and depression.
Substance Abuse
Substance abuse is a complex problem that involves a variety of factors, including the
high-stress nature of the job, the availability of substances, and the culture within the fire service.
The nature of the job itself can contribute to substance abuse. Firefighters are exposed to
traumatic events, which can lead to conditions like PTSD, compassion fatigue, and burnout.

28
According to a study published in the Journal of Dual Diagnosis, about 20% of firefighters and
paramedics had PTSD, compared to the general population rate of 3.5% (Leonard et al., 2023).
By comparison, a study of 478 male firefighters found that smoking rates of 13.6% were lower
than the general population, but smokeless tobacco use was significantly higher than the general
population at 18.4%. Within the same study, firefighters reported drinking 10 days per month,
with 56% admitting to binge drinking and 9% to driving while intoxicated (Poston, 2012). A
National Institute of Health longitudinal study of 322 firefighter recruits from seven metro fire
departments followed firefighter recruits from the fire academy through their 3rd year of
employment. The study compared drinking rates between male and female firefighters,
concluding that male firefighters drink more than female firefighters but at a consistent rate of
consumption. However, female firefighters reported an increased rate of drinking over time
(Figure 5). The same study revealed that rates of binge drinking three or more times per month
doubled among female firefighters during their first 3 years (9%–18%), whereas the rates of
male firefighters decreased from 34% to 25% within the same period (Gulliver, Zimering, et al.,
2019). Similar populations, such as the military, report heavy drinking as high as 9% among
women and 67% among men, with binge drinking occurring in 31% of women and 48% of men
(Carey et al., 2011). This high-stress environment can lead some firefighters to self-medicate
with alcohol or drugs as a coping mechanism.

29
Figure 1
Median Drinks per Week for Male and Female Firefighters
Note. From “Alcohol use and mental health symptoms in female firefighter recruits,” by S. B.
Gulliver, R. T. Zimering, F. Dobani, M. L. Pennington, S. B. Morissette, B. W, Kamholz, J. A.
Knight, T. M. Keane, N. A. Kimbrel, T. P. Carpenter, & E. C. Meyer, 2019, Occupational
Medicine, 69(8–9), p. 629. (https://doi.org/10.1093/occmed/kqaa015). Copyright 2020 by the
authors.
The availability of substances of abuse can also contribute to the problem. Firefighters
often have access to prescription medications due to their role in EMS. This easy access can lead
to misuse and addiction. Up to 10% of active firefighters actively abuse prescription-only
medications such as opioids (Smith, 2024).
The culture within the fire service can play a role in substance abuse. The fire service is
characterized by a macho culture that discourages showing weakness or seeking help. This can

30
make it difficult for individuals struggling with substance abuse to seek help. Subsequently, the
camaraderie and bonding that often occur after shifts can sometimes involve alcohol, as low
alcohol consumption may relieve anxiety (Kushner et al., 2000). However, dependence on
alcohol for relief can contribute to a culture of heavy drinking. Studies have found a correlation
between people and their social networks, which is concerning for firefighters since they work
together over extended periods (Rosenquist et al., 2010).
Many fire departments are taking steps to address this issue. Some departments have
implemented random drug testing, while others have established peer support programs to help
firefighters cope with stress and trauma. There is also a growing recognition of the need for
mental health services within the fire service.
Marriage and Divorce
Suicide rarely, if ever, will occur in a social vacuum. The impact on one’s family is a
significant consideration for those struggling with suicidality. Anecdotally, many firefighter
suicides have occurred following a separation or divorce (Cart, 2022). The true prevalence of this
occurrence is obscured by the lack of accurate reporting of firefighter suicides, as previously
discussed. However, the impact of emotional upheaval, financial instability, and grief caused by
divorce likely raise the psychological stress of the individual. Such stress and anxiety are
contributing factors to suicide. Among the general U.S. population, divorced and separated
individuals are more than twice as likely to commit suicide, with a relative risk of 2.08. Being
single or widowed did not affect suicide risk (Kposowa, 2000).
Marriage has been demonstrated to be protective of several health outcomes. Research
has noted decreased rates of heavy alcohol consumption and depression among married
firefighters (Haddock et al., 2016). An intact marriage and family structure can also help

31
stabilize individuals in stressful situations. In an extreme example of the occupational stress
firefighters undergo, reports of injury, physical illness, and psychological strain among the New
Orleans Fire Department prompted a cross-sectional study on depression levels among New
Orleans firefighters following Hurricane Katrina. The National Institutes for Occupational Safety
and Health (NIOSH) conducted a health hazard evaluation. The study evaluated New Orleans
firefighters 13 weeks after Hurricane Katrina struck. Due to the disaster’s catastrophic nature,
many families were displaced, including those of firefighters. The study found that firefighters
who were currently living with their families were less likely to report depressive symptoms
(prevalence ratio of 0.7) than those not living with their families (Tak et al., 2007). These results
suggest a protective effect of having one’s family intact and present on mental health and the
ability to process stressors.
In contrast, divorce has been associated with poorer health outcomes, including higher
rates of substance abuse and early mortality. In a study published after a 40-year follow-up
examining divorce and health outcomes, being separated or divorced at every marital status
assessment was found to confer a more significant increase in mortality than being a current
smoker (Figure 6). Separated and divorced men evinced more significant morbidity and
mortality compared to separated and divorced women, with a hazard ratio of 1.44. The effect of
separation or divorce was eliminated when the category was expanded to include all participants
who had ever experienced separation or divorce during the follow-up. This result infers that
experiencing one marital breakup is not enough to alter one’s mortality risk. While the majority
of those who divorce do remarry (Lewis et al., 2015), 25% or more do not (Bramlett & Mosher,
2001).

32
Figure 2
Survival Curves Comparing Baseline Assessment and Marital Status With Three Different
Classifications
Note. From “Divorce and Death,” by D. A. Sbarra, & P. J. Nietert, 2009, Psychological Science,
20(1), p. 110. (https://doi.org/10.1111/j.1467-9280.2008.02252.x). Copyright 2009 by
Association for Psychological Science.
Popular publications report higher-than-average divorce rates among firefighters, but few
studies have substantiated those claims. Fire Engineering, a leading industry periodical, states
that the divorce rate for firefighters is three times that of the general population (Gagliano,
2009). A study examining epidemiological data from 31 fire departments in the United States
sought to substantiate this perception but demonstrated stark differences between male and
female firefighters’ marital statuses (Figure 7; Haddock et al., 2016). Of the 1,456 participants in
the study, 3.4% were women, which is consistent with the national rate of women in the fire
service. Based on U.S. Census data, male firefighters had a divorce rate comparable to the public
(11.8% versus 9.4%, respectively). Female firefighters, on the other hand, were more than three
times more likely to be divorced compared to the public (32.1% vs. 10.1%). Male firefighters
were more likely to be married than the public, while female firefighters were less likely. When

33
examining every divorce among firefighters in the study, as seen in Figure 7, women had higher
rates than men across all age groups (40.0% vs. 24.4%). A more recent but smaller study of 163
firefighters in the southern United States found a similarly high rate of divorce among female
firefighters (42%) but a higher rate of divorce among men (33%; Pennington et al., 2021).

34
Figure 7
Prevalence of Ever Divorce Among Firefighters by Age
Note. From “Marriage and Divorce Among Firefighters in the United States,” by C. K. Haddock,
S. A. Jahnke, W. S. C. Poston, N. Jitnarin, & R. S. Day, 2016. Journal of Family Issues, 37(16),
p. 2302. (https://doi.org/10.1177/0192513X15583070). Copyright 2015 by the authors.
Fire Service Cultural Barriers
The work environment of firefighters differs from other fields, which can negatively
impact the efforts to seek mental health assistance (Jones et al., 2020). The social dynamics of
the fire service can suppress the outward display of emotion, as empathy can be seen as a
weakness (Thurnell-Read & Parker, 2008). Fire departments have adopted employee assistance

35
programs, peer support groups, and critical incident stress debriefings to address mental health
complications. However, rates of PTSD, compassion fatigue, burnout, and suicide continue to
rise each year (Jones et al., 2020). Currently, no research documents these programs as
successful intervention methods (Priebe & Thomas-Olson, 2013).
A study conducted in 2020 surveyed 314 firefighters to identify perceived barriers when
they attempted to report a behavioral or mental health complication (Thews et al., 2020). The
study utilized an online survey format and discovered cultural barriers such as embarrassment
from co-workers on the condition, a fear of being ostracized and shunned for future promotions,
and a chronic stigma of not being a fit firefighter. Additionally, structural barriers were
identified, such as difficulty filing a claim, change in occupational status, and not receiving
adequate recovery time (Table 3). Supplementary research found that those who have sought out
help for mental health are reluctant to reappear for assistance or endorse their clinicians to others
(Owens et al., 2009).

36
Table 3
Descriptive Statistics of Perceived Barriers
Perceived barriers Frequency of
reported barrier
n (%)
Level of
difficulty mode
Frequency of
highest mode
n/n (%)
Embarrassment of condition 182/314 (58.0) 3 77/182 (42.3)
Jeopardizing current and/or future
career
141/314 (44.9) 3 59/141 (41.8)
Stigma of not being a healthy and fit
firefighter
115/314 (36.6) 3 53/115 (46.1)
Change in duty status 104/314 (33.1) 3 34/104 (35.6)
Feeling of letting fellow firefighters
down
103/314 (32.8) 4 47/103 (45.6)
Accepting pain as a natural part of
the job
92/314 (29.3) 3 31/92 (33.7)
Difficulty filing a worker’s
compensation claim
77/314 (24.5) 4 28/77 (36.4)
Lack of knowledge about when to
seek care
75/314 (23.9) 3 33/75 (44.0)
Inability to determine if the condition
was caused at work or otherwise
70/314 (22.3) 4 24/70 (34.3)
Not getting time off for personal
healing
62/314 (19.7) 3 24/62 (38.7)
Lack of healthcare education services
available
61/314 (19.4) 3 21/61 (34.4)
Absenteeism as a result of the injury 55/314 (17.5) 4 20/55 (36.4)
Fear of worst-case scenario 54/314 (17.2) 4 29/54 (53.7)
Pay reduction/unable to take off
without pay
50/314 (15.9) 3 22/50 (44.0)
Inadequate support from local
authorities (e.g., human resources,
city officials)
50/314 (15.9) 4 21/50 (42.0)
Medical services provided are not
helpful
46/314 (14.6) 3 21/46 (45.7)
Commitment to family 44/314 (14.0) 4 21/44 (47.7)
Poor communication 36/314 (11.5) 3 15/36 (41.7)
Time away from the job needed to
report
33/314 (10.5) 3 12/33 (36.4)
Lack of access to a healthcare
provider
31/314 (9.9) 3 14/31 (45.2)
Lack of benefits (e.g., health
insurance)
28/314 (8.9) 4 12/28 (42.9)
Lack of knowledge in reporting
structure
27/314 (8.6) 3 9/27 (33.3)

37
Perceived barriers Frequency of
reported barrier
n (%)
Level of
difficulty mode
Frequency of
highest mode
n/n (%)
Home treatments are sufficient to
deal with the problem (e.g.,
medicine, ice, heat pad, meditation)
27/314 (8.6) 1 8/27 (29.6)
Ease of scheduling appointments 23/314 (7.3) 3 11/23 (47.8)
Fear of discipline from supervisor 21/314 (6.7) 3 7/21 (33.4)
Lack of department financial
resources
16/314 (5.1) 3 6/16 (37.5)
Leadership discourages reporting 15/314 (4.8) 2 6/15 (40.0)
Lack of organizational support during
probationary period
13/314 (4.1) 4 8/13 (61.5)
Nearing retirement 10/314 (3.2) 3 5/10 (50.0)
Race/ethnicity 2/314 (0.6) 3 1/2 (50.0)
Note. Level of difficulty: 4 = extremely challenging; 3 = very challenging; 2 = moderately
challenging; 1 = slightly challenging. From “Perceived barriers to reporting mental and
behavioral illness in the fire service,” by K. N. Thews, Z. K. Winkelmann, L. E. Eberman, K. A.
Potts, & K. E. Games, 2020. International Journal of Athletic Therapy and Training, 25(1), 31–
36. Thews et al., 2020. Copyright 2020 by the authors.
Industry Standards and Recommendations
No standardized federal, state, or local framework is used to mandate specific mental
health mitigation actions in the fire service. However, nationally, fire service organizations are
receiving concerning statistics on firefighter behavioral health, leading to new recommendations
that frame how fire departments alleviate these challenges. Five organizations that will be
studied include the FBHA, the IAFF, the NVFC, the NFFF, and the USFA. Furthermore, the
federal government utilizes specific standards from OSHA and the NIOSH to address fire safety,
not firefighter mental health.

38
The Occupational Safety and Health Act of 1970 established OSHA to ensure workers’
safe working conditions. A U.S. federal agency, OSHA mandates safety standards, provides
educational resources and outreach, and conducts inspections to enforce workplace safety
regulations (OSHA, 2023). Its primary responsibility is to ensure that employers provide safe
and healthy working environments for their employees, and it accomplishes this through setting
and enforcing safety standards, offering training and education on workplace safety, and
conducting inspections. By reducing workplace injuries, illnesses, and fatalities, OSHA helps to
protect the workforce and promote a healthy economy. Its mission is to empower workers to
speak up about unsafe conditions and to ensure that employers are held accountable for
providing safe work environments. Overall, OSHA plays a vital role in promoting workplace
safety and health and helping to ensure that workers return home safely at the end of each
workday.
Specifically for the fire service, OSHA provides safety information on how buildings and
fire protection systems within such buildings interact with firefighting activities. OSHA requires
reporting all physical but not mental injuries on the job. The agency has no protocols that address
workplace stress and does not regulate mental health hazards, but it does consider PTSD an
injury if an on-duty event causes it. How to delineate if an on-duty event caused PTSD compared
to a preexisting circumstance is convoluted. Subsequently, OSHA offers employees access to
services that can support PTSD but not any other mental health conditions.
The NIOSH is a federal agency dedicated to protecting workers from harm in the
workplace. Through their research, guidance, and collaboration with industry partners, they
strive to create safer work environments and prevent work-related injuries, illnesses, and deaths.
NIOSH’s focus on engineering controls, personal protective equipment, and workplace

39
interventions helps provide science-based solutions to improve workplace safety and health. As
part of the CDC, NIOSH promotes worker well-being and prevents workplace hazards. It is
dedicated to protecting firefighters’ health and safety by conducting research, providing training,
and making recommendations to reduce risks associated with firefighting. The agency studies
firefighters’ hazards, including exposure to toxic substances and traumatic injuries, and guides
best practices to reduce these risks. In addition, NIOSH collaborates with stakeholders to
develop and promote interventions protecting firefighters’ physical and mental health. By
providing science-based solutions, NIOSH helps ensure firefighters can perform their critical
work while minimizing the risk of injury or illness. Overall, NIOSH plays a critical role in
promoting the health and safety of firefighters but fails to generate firefighter mental health
practices that can set the industry standard, consistent with other best practice frameworks
produced by the agency.
Firefighter Behavioral Health Alliance
The Firefighter Behavioral Health Alliance is a non-profit organization that raises
awareness and provides resources to enhance first responders’ and firefighters’ mental health and
well-being (FBHA, 2022). The organization was established in 2011 by Jeff Dill, a licensed
counselor and former firefighter who recognized the need for greater attention to the mental
health issues affecting these individuals. The FBHA provides training, education, and resources
to help first responders and firefighters identify and manage mental health concerns such as
stress, trauma, and suicidal ideation. The organization also collects and evaluates data on
suicides/mental health among first responders and firefighters in the United States to create
initiatives and resources to reduce these incidents. For example, a survey was conducted of 479
firefighters across nine fire/EMS departments by the FBHA, exploring moral injury in fire

40
service personnel using the Moral Injury Outcomes Scale (Dill et al., 2023). Their results
indicated that 57.6% of firefighters report having experienced a morally injurious event. These
include events involving abuse, injured children, mass shootings, feelings of guilt, car accidents,
and incidents that include making decisions that affect the survival of others.
Table 4 explores additional findings from this study. Notably, 49.8% of respondents
admitted feeling isolated and emotionally detached, a known behavioral health stressor. Survey
findings revealed that firefighters might not comprehend the definition of “moral injury” or its
delineation from PTSD. Furthermore, the study concluded that more firefighters died by suicide
than in the line of duty from 2014-2020. While FBHA records reported firefighter suicides, the
numbers may not accurately depict how many suicides occur. Therefore, firefighter suicide
might represent a more significant challenge than reported. In addition, FBHA supports families
who have lost a first responder or firefighter to suicide or those who struggle with mental health
manifestations. The organization strives to combat mental health stigma by encouraging first
responders and firefighters to seek help. However, seeking help is difficult for firefighters
because they worry about the stigma of being labeled unfit to continue their line of work (FBHA,
2022). Therefore, the FBHA is a critical organization that focuses on improving first responders’
and firefighters’ mental and overall well-being while increasing awareness and education on
behavioral and mental health.

41
Table 4
Affirmative Responses to PTSD Symptoms
PTSD symptom questions Yes %
In the past month have you had nightmares about the event or
thought about the event when you did not want to?
101 36.59%
In the past month have you tried hard not to think about the event or
went out of your way to avoid situations that reminded you of the
event(s)?
102 36.96%
In the past month have you been constantly on guard, watchful, or
easily startled?
88 32.00%
In the past month have you felt detached from people, activities, or
your surroundings?
137 49.82%
In the past month felt guilty or unable to stop blaming yourself or
others for the event(s) or any problems the event(s) may have
caused?
100 36.23%
Note. Adapted from Wounds of the Spirit: Moral Injury to Firefighters (White Paper Series
No.1) by J. Dill, M. Schimmelpfennig, & E. Anderson-Fletcher, 2023. Firefighter Behavioral
Health Alliance. In the public domain. Adapted from “Defining and Assessing the Syndrome of
Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium,” by B. T. Litz, R.
A. Plouffe, A. Nazarov, D. Murphy, A. Phelps, A. Coady, S. A. Houle, L. Dell, S. Frankfurt, G.
Zerach, & Y. Levi-Belz, 2022, Frontiers in Psychiatry, 13, Article 923928.
https://doi.org/10.3389/fpsyt.2022.923928). Copyright © 2022 Litz, Plouffe, Nazarov, Murphy,
Phelps, Coady, Houle, Dell, Frankfurt, Zerach, Levi-Belz and the Moral Injury Outcome Scale
Consortium. Adapted from “The primary care PTSD screen for DSM-5 (PC-PTSD-5):
Development and Evaluation Within a Veteran Primary Care Sample,” by A. Prins, M. J. Bovin,
D. J. Smolenski, B. P. Marx, R. Kimerling, M. A. Jenkins-Guarnieri, D. G. Kaloupek, P. P.
Schnurr, A. P. Kaiser, Y. E. Leyva, & Q. Q. Tiet, 2016, Journal of General Internal Medicine,
31(10), 1206–1211. (https://doi.org/10.1007/s11606-016-3703-5). Copyright 2016 by Society of
General Internal Medicine.

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The International Association of Firefighters
The IAFF is a labor union representing professional firefighters and EMS personnel in
the United States and Canada. Its primary aim is to safeguard and support the welfare of its
members, including ensuring equitable pay, benefits, and favorable working conditions. Besides
negotiating collective bargaining agreements, the IAFF endeavors to elevate safety standards and
foster training and education opportunities for firefighters and EMS personnel. Through lobbying
at different levels, the IAFF advocates for legislation that advances the interests of its members
and public safety initiatives that serve the communities. Overall, the IAFF is an organization that
plays a crucial role in the firefighting profession by championing the members’ interests and
striving to enhance safety and training standards.
The IAFF recognizes the significant impact that firefighting can have on a firefighter’s
mental health and has taken several initiatives to support the mental health of its constituents.
Below are ways the IAFF assists with mental health:
• Peer support programs: The IAFF offers peer support programs that provide a safe
and confidential space for firefighters to talk to other firefighters who have
experienced similar mental health challenges. Training for teams includes general and
suicidal assessments, confidentiality, crisis intervention, self-care, and active listening
(IAFF, 2021).
• IAFF Center of Excellence for Behavioral Health Treatment and Recovery
(CEBHTR): The IAFF has established a facility that provides specialized treatment
for firefighters and EMS personnel who struggle with PTSD, burnout, compassion
fatigue, addiction, and other mental health conditions. The CEBHTR is staffed with
clinicians and physicians who utilize cognitive behavioral therapy, dialectical

43
behavioral therapy, eye movement desensitization and reprocessing, and group/family
therapy as options to treat mental health issues (IAFF Center of Excellence for
Behavioral Health Treatment and Recovery, 2023).
• advocacy: policies and resources that support mental health in the firefighting
profession, including access to mental health care and peer support programs
• Education and training programs that teach firefighters to identify and mitigate
mental health problems such as depression and PTSD. The IAFF (2020) stated that
40% of firefighters have some form of sleep disorder (insomnia, obstructive sleep
apnea, shift work disorder, restless leg syndrome). Obesity, injuries, strokes, cancer,
cardiovascular disease, diabetes, depression, and weight gain are linked to insufficient
sleep. The IAFF’s Wellness Fitness Initiative is aiding fire departments to recognize
the signs of sleep deprivation while guiding them to resources that can build effective
initiatives to mitigate the negative manifestations of not sleeping enough. Overall, the
IAFF is committed to promoting the mental well-being of firefighters and EMS
personnel and recognizes that mental health is as crucial as physical health.
The International Association of Fire Chiefs
The IAFC is an association that serves as a professional organization for fire chiefs and
other emergency service professionals worldwide. Since its establishment in 1873, it has
amassed over 12,000 members in over 80 countries. The IAFC provides leadership, education,
and advocacy for the fire service. The group strives to enhance the safety and effectiveness of
firefighting and emergency services through its resources, which include training programs,
conferences, publications, and networking opportunities. In addition, the IAFC collaborates with
other organizations and government agencies to boost fire safety and readiness.

44
Additionally, the group supports policies that benefit the fire service and provides help
during disasters and emergencies. The IAFC understands the significant role of addressing the
mental health of firefighters and emergency responders. As such, it has made efforts to raise
awareness about mental health challenges these professionals face and promote the availability
of resources and support to help them manage the stress and trauma that come with their work.
To support behavioral health in the fire service, the IAFC has initiated various programs,
including educational initiatives, peer support networks, and partnerships with mental health
organizations. Additionally, the IAFC has created policies and guidelines to promote the best
practices in dealing with behavioral health in the fire service.
However, the best practices for behavioral wellness are currently vague and do not offer
explicit guidance. For example, Best Practice 1 advises creating psychological safety within the
fire department but delivers no framework for accomplishing this task. Apart from these
measures, the IAFC has actively advocated for policy and legislative changes to increase access
to behavioral health services for firefighters and emergency responders. These measures include
calling for higher funding for mental health programs and advocating for adjustments to
workers’ compensation laws to ensure these professionals receive the necessary care. Overall,
the IAFC acknowledges the significance of addressing behavioral health in the fire service and
pledges to support firefighters and emergency responders regarding their mental health and wellbeing (IAFC, 2023).
National Volunteer Fire Council
The NVFC is a non-profit organization that speaks on behalf of the volunteer fire, EMS,
and rescue services in the United States. It was founded in 1976 and is comprised of state-level
groups for volunteer firefighters, individual firefighters, and emergency responders. The NVFC

45
functions as a supporter of volunteer emergency services at the national level. It collaborates
with government agencies, legislators, and other organizations to advocate for the interests of
volunteer firefighters and emergency responders. In addition, the NVFC provides various
resources and programs to bolster the volunteer fire service, such as training and education,
initiatives to improve health and safety, and promoting better resources and funding. The
NVFC’s advocacy efforts aim to guarantee that volunteer fire departments have the equipment,
training, and resources to safeguard their communities and manage emergencies. The
organization also encourages recruiting and retaining volunteer firefighters, recognizing their
significant role in securing public safety.
The NVFC advocates for the interests of volunteer firefighters and EMS workers and
offers a variety of resources and assistance to its members, including training, information about
health and safety issues, and advocacy. A significant concern the NVFC has focused on lately is
the mental health and wellness of emergency responders exposed to traumatic experiences and
chronic stress that can result in various behavioral health issues like anxiety, depression, and
PTSD. To address these challenges, the NVFC has implemented numerous programs and
resources, including the Share the Load Initiative, which provides confidential and free
counseling services for firefighters and their families. The NVFC also offers a Behavioral Health
Toolkit, which provides guidance on promoting mental health and well-being within fire
departments. The NVFC’s mission is to support emergency responders’ overall health and
promote an environment of mental health awareness and support within the firefighting
community (NVFC, 2021).

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National Fallen Firefighters Foundation
The NFFF began in 1992 as a non-profit organization to support and honor firefighters
who lost their lives while on duty. Their main objective is to provide resources and aid to the
families of deceased firefighters and raise awareness of firefighter safety to prevent further
deaths or injuries. The NFFF provides various programs and services that support the families of
deceased firefighters, including financial aid, resources for survivors, and scholarships for the
children of fallen firefighters. Additionally, the organization annually conducts the National
Fallen Firefighters Memorial Weekend in Emmitsburg, Maryland, to commemorate firefighters
who have passed away while on duty.
The NFFF collaborates with fire departments, government agencies, and other
organizations to promote firefighter safety and prevent deaths and injuries while on duty. It also
conducts research, provides training and education on firefighter safety, and focuses on
firefighter health issues (NFFF, 2023). The NFFF acknowledges the significance of behavioral
health for first responders, including firefighters, who encounter stressful and traumatic events
that could have a long-term impact on their mental health and general well-being. As a result, the
NFFF has created a comprehensive behavioral health program to provide training, education, and
support services to firefighters and their families. This program aims to enhance mental health
awareness, cultivate resilience, and provide resources for those experiencing mental health
issues. However, these programs are reactive and emphasize a lack of mental health knowledge.
They do not provide specific program design/implementation or structured changes within the
organization to assess and correct behavioral abnormalities.
Furthermore, the NFFF hosts an annual behavioral health symposium where
professionals and interested parties from the fire service and mental health sectors gather to

47
discuss innovative research and best practices on behavioral health in the fire service. The NFFF
also collaborates with the Firefighter Behavioral Health Alliance to gather information on
suicides among first responders, including firefighters, to design methods to prevent these
incidents and aid affected individuals. The NFFF is dedicated to boosting firefighters’ and first
responders’ behavioral health and overall well-being, recognizing that mental health is crucial in
ensuring their safety and effectiveness as they serve their communities.
National Fire Protection Association
The NFPA is a global non-profit organization aiming to alleviate the risks of fire hazards
through scientifically based codes, standards, research, training, and education. It was established
in 1896 and had its headquarters in Quincy, Massachusetts. The NFPA’s main objective is to
decrease the likelihood of fires by creating and promoting codes, standards, and guidelines that
govern the design, installation, operation, and maintenance of various fire protection systems and
equipment. These codes and standards are diverse and encompass fire prevention, building
design, life safety, fire suppression, and emergency response issues. Moreover, the NFPA
provides training and education programs for different professionals involved in fire protection,
such as firefighters, fire inspectors, building code officials, plan examiners, and fire
investigators. In addition, the organization collaborates with government agencies, industry, and
other stakeholders to foster fire safety and generate novel technologies and practices to prevent
fires (NFPA, 2021b).
The NFPA also acknowledges the significance of addressing behavioral health concerns
that firefighters and other first responders may face due to their exposure to stressful and
traumatic events. It developed various initiatives and resources to address these issues, such as its
behavioral health program, which offers guidance and resources to fire departments and

48
firefighters to manage behavioral health concerns. This program includes tools like a guide for
fire chiefs, a self-assessment tool for firefighters to assess their mental health, and training
courses on topics like PTSD and suicide prevention. The NFPA also advocates for legislative
and policy changes that promote behavioral health in the fire service, such as providing funding
for mental health services and raising awareness of mental health support in fire departments.
Ultimately, the NFPA recognizes the importance of promoting behavioral health in the fire
service while providing resources and support to maintain firefighters’ mental health and wellbeing.
United States Fire Administration
The USFA is a government organization that operates under the Federal Emergency
Management Agency within the U.S. Department of Homeland Security. Its main goal is to offer
direction, coordination, and aid in nationwide fire prevention, control, and emergency response.
The USFA collaborates with local and state fire departments and other groups to advance fire
prevention and safety by providing firefighter training and education, promoting fire science
research and development, and aiding communities recovering from fire-related disasters.
Moreover, the agency collects and examines data on fire-related incidents and patterns, utilizing
the information to improve fire prevention and response methods. The USFA recognizes that the
mental security of firefighters and emergency responders is crucial. As such, it has instituted
several programs and measures to cater to their behavioral health needs. One of the USFA’s
noteworthy undertakings is the National Firefighter Registry, which captures data on the safety
and health of firefighters, including mental health concerns like stress, depression, and anxiety.
Furthermore, the USFA provides firefighters and fire departments training and resources
to help them manage and address any psychological challenges they might experience. Also, the

49
USFA has formed partnerships with organizations such as the NFFF and the Firefighter
Behavioral Health Alliance to promote best practices and awareness for behavioral health issues
within the firefighting sector. The USFA recognizes the significance of behavioral health in
guaranteeing the safety and overall health of firefighters and emergency responders. It is devoted
to supporting their mental wellness throughout the United States.
Clark and Estes’s Gap Analysis Framework
Clark and Estes’s (2008) gap analysis framework is a diagnostic tool used in training and
organizational development. The framework helps to identify the foundational causes of
organizational performance gaps. It is based on the understanding that performance issues in an
organization can be traced back to deficiencies in one or more of the categories of knowledge,
motivation, and organizational influences. Using Clark and Estes’s gap analysis framework, an
organization can systematically examine each area to identify specific issues that contribute to a
performance gap. Once identified, targeted interventions can be developed to address these gaps,
improving organizational performance. This framework is effective because it emphasizes a
holistic approach to diagnosing and addressing performance issues rather than simply focusing
on one aspect of organizational functioning.
Anytown Fire Department’s Knowledge, Motivation, and Organizational Influences
Clark and Estes’s (2008) framework was developed to identify the obstacles to
organizational change and performance improvement. This model suggests that three basic
principles, namely knowledge, motivation, and organizational factors, must coincide to achieve
effective organizational performance improvement. The knowledge factor ensures that
individuals in the organization have the skills and understanding to perform their tasks, and
performance gaps could be attributed to a lack of requisite knowledge or skills. Training and

50
education are typical solutions to knowledge gaps. The motivational factor includes incentives,
attitudes, and external or internal factors guiding behavior and performance. Even highly skilled
employees may only perform effectively with motivation, and motivational challenges can
involve examining organizational culture, feedback mechanisms, and reward systems. The
organizational factor comprises structures, cultures, and processes supporting or hindering
performance. Organizational barriers can prevent effective performance, such as a culture that
does not support desired behaviors, poor process design, or inadequate resources. Together, these
three pillars make up the knowledge, motivation, and organizational (KMO) influences
framework.
In practice, the KMO framework can diagnose organizational performance problems and
guide the development of comprehensive solutions that address all relevant factors, emphasizing
an all-inclusive approach to performance improvement. The following section includes a detailed
analysis of AFD’s particular KMO influences related to behavioral health programs within the
department, providing a deeper understanding of the factors that impact the department’s overall
performance—emphasizing a universal approach to performance improvement. The following
section includes AFD’s particular KMO influences related to behavioral health programs within
the department.
Knowledge and Skill Influences
Identifying primary causes of performance gaps within organizations and developing
practical solutions requires carefully considering various factors, including KMO influences
(Clark & Estes, 2008). These three factors are interrelated and work in tandem to achieve
optimal performance, much like the four cardinal virtues of the Stoics. The Stoics believed that
living a virtuous life guided by courage, justice, wisdom, and temperance would lead to inner

51
peace and harmony with the universe (Robertson, 2020). They understood these virtues were
interdependent and mutually reinforcing, like how KMO influences interact within an
organizational context. Identifying and implementing practical solutions to address performance
gaps necessitates a general approach that considers the interplay among these various factors.
These virtues were interdependent and mutually reinforcing, like how KMO influences work
together.
Knowledge provides the foundation for informed decision-making. Having accurate,
comprehensive knowledge allows individuals to make decisions that are more likely to lead to
successful outcomes (Clark & Estes, 2008). Therefore, knowledge, as it relates to KMO, refers to
the information provided to an organization to succeed and whether personnel understand how to
achieve their performance goals with this information. For AFD, the goal is to build a behavioral
health component into the current health and wellness program that will benefit all AFD
personnel.
The NFPA has industry standards for health and wellness, which include several
behavioral health components (NFPA 1500 and NFPA 1583). More firefighters die from suicide
annually than in the line of duty, and additional suicides are likely unreported (FBHA, 2022). A
recent study (Heyman et al., 2018) found that firefighters and police personnel are five times
more likely to suffer symptoms of depression and PTSD than the general population, leading to
higher rates of suicide. A study from Florida State University of one thousand firefighters found
that at some time during their career, 47% considered suicide, 19% made plans for suicide, and
16% went through with a suicide attempt (S. Hom et al., 2015). During the recent U.S. Fire
Administrator’s Summit on Fire Prevention and Control, behavioral health was one of six critical
issues identified that impacted the current state of the fire service. Subsequently, 73% of all fire

52
departments in the United States do not have a behavioral health program (NFPA, 2021b). It is
unclear how the 27% of U.S. fire departments with behavioral health programs educate and train
their personnel. Anytown FD has not established initial or continuing behavioral health
education for its personnel.
Change occurs as a process and is instrumental in acquiring new knowledge and skills.
Obtaining new knowledge and skills increases an organization’s ability to balance the personal,
behavioral, and environmental factors influencing the desired change (Ozer, 2022; Paglis &
Green, 2002). Without educating AFD personnel on identifying and mitigating behavioral health
challenges, there cannot be an expectation that the organizational culture will positively change.
However, acquiring knowledge through information dissemination must present an opportunity
for firefighters to demonstrate their comprehension of the information, as education should not
be expected to provide how-to information (Clark & Estes, 2008). Subsequently, AFD should
include multiple types of knowledge in the context of education, training, and organizational
performance.
Knowledge comprises four types: factual (also referred to as declarative), procedural,
conceptual, and metacognitive (Clark & Estes, 2008; Star & Stylianides, 2013). Factual
knowledge refers to the know what aspect, which is about factual information. It involves
understanding what something is, such as what fire station runs the most calls. Procedural
knowledge is the know-how aspect involving skills and processes. It is about knowing how to do
something, such as pulling a fire hose or starting an IV. This knowledge is gained through
practice and experience (Hurrell, 2021). Metacognitive knowledge involves an awareness and
understanding of one’s thought processes. It goes beyond knowing or understanding information;
it is about knowing how you think, learn, and solve problems. Understanding how our beliefs

53
and experiences influence our attitudes toward causes and mental health prevention would be an
example of metacognitive knowledge. Conceptual knowledge refers to an understanding of
complex ideas and systems. It involves grasping the underlying principles, such as the hydraulic
calculations for operating the fire truck’s elevated master stream. This type of knowledge goes
beyond just knowing the facts (factual) or how to do things (procedural); it is about linking
various pieces of knowledge together (Schneider et al., 2011).
Content Knowledge for Behavioral Health and Wellness
Content knowledge refers to the understanding and mastery of a specific subject matter
(Kleickmann et al., 2013). It is the in-depth information, concepts, theories, and skills related to a
particular profession. This type of knowledge is essential for professionals and those aspiring to
be subject matter experts, as it forms the basis of their expertise and ability to impart information
effectively. Content knowledge encompasses the technical and theoretical understanding
necessary to perform the job competently (Loewenberg Ball et al., 2008). For example, AFD’s
firefighter/paramedic’s content knowledge includes understanding human anatomy, medications,
and medical interventions under their scope of care. Therefore, content knowledge is
complemented by practical skills and experience in applying that knowledge effectively in the
organization. Balancing knowledge with self-inquiry makes firefighters more adaptable,
empathetic, and effective. They can understand their biases and limitations, leading to better
decision-making. However, when firefighters conduct self-inquiry, they may incorporate ideas
based on prior knowledge and experience that conflict with their understanding of the knowledge
they seek (Al Mamum et al., 2020). Therefore, teaching firefighters about behavioral health is
insufficient to ensure comprehension; the pedagogical knowledge strategies from educators are

54
necessary to erode the common misconceptions firefighters may possess and diversify teaching
styles (Kleickmann et al., 2013).
Increasing knowledge, skills, and motivations will help organizations with their ability to
solve problems and adapt to changes (Clark & Estes, 2008). When firefighters are encouraged to
expand their ideas, they receive a platform to articulate their views and reflect on them critically
(Kearney, 2002). This pedagogical method of educating is known as scaffolding (Gunstone &
Brew, 1992) and offers learners an indirect intervention to promote their knowledge (Won et al.,
2014). As Pritchard and Woollard (2010) stated, the concept of scaffolding is built upon the zone
of proximal development, which Vygotsky (1978) defined as the gap between what a learner
accomplishes independently and what they can accomplish with the assistance of a more capable
other.
The Phoenix Regional Fire Academy is the initial introduction to education for AFD. Fire
recruits spend 20 weeks at the academy before they graduate and transition to the field. For
many, this will be their first occupational education in the fire service, and they are expected to
apply the knowledge they learn in the classroom to practical skills in the field. They will be
given daily feedback on their performance and evaluated for areas of improvement. The AFD
does not contribute to the content knowledge of the academy. The curriculum is designed by the
Phoenix Regional system, without input from AFD, and does not include any behavioral health
components. Therefore, AFD must have the content knowledge of suicide, compassion fatigue,
burnout, sleep deprivation, and PTSD at all knowledge levels to effectively instruct firefighters.
Efficacious instruction at the declarative level of behavioral health involves firefighters knowing
suicide surpasses line-of-duty deaths, and firefighters report PTSD at a rate five times the general
population. Effective instruction at the conceptual level of behavioral health encompasses

55
firefighters reflecting on their behaviors/attitudes and how they impact their mental health.
Successful instruction at the procedural level of behavioral health involves firefighters critically
thinking about positive pathways to channel stress and what impact that stress mitigation has on
their wellness. Effective teaching at the metacognitive level of behavioral health embodies
firefighters’ ability to recognize how their biases affect their likelihood of seeking help for
behavioral health challenges.
Becoming an expert through content knowledge involves a deep and comprehensive
understanding of a specific subject area. Creating pedagogical systems that benefit firefighters
requires believing that knowledge capacities are not fixed but formed over time (Dweck &
Yeager, 2019). Historically, the fire service has yet to inherit education on human dynamics and
the intersectionality of job duties on behavioral health. The paradox of experience (skills) versus
education (knowledge) continues to play a controversial role, even though they work
synergistically to form a growth mindset. A growth mindset encourages continuous learning and
skill development, which is critical for building a behavioral health program through knowledge
and skill acquisition.
Pedagogical Knowledge for Behavioral Health and Wellness
Pedagogical content knowledge is a concept that refers to the specific knowledge
educators need to effectively teach a particular subject. Where content knowledge is expertise in
a specific area, pedagogical knowledge refers to general principles and strategies of teaching and
learning, including how students learn, classroom management, lesson planning, and student
assessment. Pedagogical knowledge goes beyond the subject matter; it is about knowing how to
make the subject matter understandable to others (Van Driel & Berry, 2012).

56
Fire service instructors deliver information to increase firefighters’ knowledge, but it
remains unclear what pedagogical content knowledge is required for effective instruction.
Replicating a similar program from a neighboring fire department is a standard process for AFD.
This needs to be improved on multiple levels. First, the content knowledge of program
development and implementation is absent, and the pedagogical knowledge of program delivery
is still being determined. An instructor needs adequate content and pedagogical knowledge to
have the desired effect on the students. Therefore, procedural knowledge of how to deliver and
implement programs is needed for suitable instructor development. Table 5 presents an
evaluative framework intended to elucidate both the content knowledge and pedagogical
expertise that HWC currently holds or is required to acquire.
Table 5
Knowledge Influences, Types, and Assessments
Assumed knowledge influence Knowledge influence assessment
Factual: AFD needs to know what
behavioral health services are
currently available.
Interview: Outside of the employee assistance
program (EAP), are there any behavioral health
services available to you?
Conceptual: AFD needs to know the
behavioral issues that lead to
firefighter suicide.
Interview: What do you think should be included in
a fire department behavior health program?
How many critical stress events have you
experienced at work?
Procedural: AFD needs the procedural
knowledge of behavioral health
implementations that reduce
suicidality.
Interview: Are you satisfied with your department’s
managing of stress management? Describe your
department’s critical incident stress debriefing.
Metacognitive: AFD personnel need
the metacognitive knowledge of how
their own beliefs and experiences
influence their attitudes toward
causes and prevention of suicide.
Interview: Do you feel your stress as a firefighter
has caused unresolved psychological/emotional
issues?

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Motivational Influences
Motivation is critical in driving employee performance and, by extension, organizational
success. Motivation influences the degree to which employees are willing to engage with their
work and exert effort toward achieving organizational goals (Clark & Estes, 2008). Marcus
Aurelius, the Roman emperor and Stoic philosopher, emphasized self-discipline as a critical
virtue of motivation. In an organizational context, this translates to individual employees
exercising self-control and diligence in their roles, motivated by personal integrity and a sense of
duty. This inner discipline can drive consistent performance and reliability, contributing to
organizational success (Meditations).
Clark and Estes (2008) emphasized identifying gaps between an employee’s current
motivational state and the optimal state needed to achieve high performance. This gap analysis
can help organizations tailor interventions to boost motivation. In their framework, motivation is
linked to performance outcomes. The authors argued that even if employees have the necessary
knowledge and skills and organizational barriers are removed, they are unlikely to apply
themselves fully to their work without sufficient motivation.
It is essential to understand that AFD has never had a behavioral health program, which
makes it difficult to gauge the motivation to incorporate one. There may be a need for more
understanding or awareness about the benefits of a behavioral health program, including how it
can improve performance, reduce callouts, and enhance overall morale. Due to a lack of
behavioral health education and curriculum in the department, this research focused on the
beliefs and conceptions of AFD. Lack of a curriculum affected the knowledge of the department,
but is the lack of motivation due to innate beliefs or organizational factors? If the department had
a negative experience with poorly designed or implemented programs, there might be a

58
reluctance to invest in another initiative. Motivational assessments include how important a
behavioral health program was to the AFD and how valuable the program could be to the
organization’s success. Additionally, motivational assessments analyze the decision-making
process to determine what factors are needed to solve adaptive challenges. The following
sections will consider the adaptive leadership model and utility value theory related to AFD.
Adaptive Leadership Model
Adaptive leadership is a pragmatic framework that assists individuals and organizations
in adapting to challenging environments by distinguishing between technical problems and
adaptive challenges. It is well suited to address complex problems where both the problem and
solution are unclear and where innovation and learning are needed. Contrary to technical
problems, which can utilize expertise and standard operating procedures, adaptive challenges
require new learning, innovation, and changes in values, beliefs, roles, relationships, and
approaches (Heifetz & Linsky, 2002). The HWC within AFD needs to identify whether the
department’s current knowledge is sufficient for a behavioral health program or if it requires new
learning and approaches. Adaptive change often involves loss and discomfort, impacting the
change initiative’s motivation. The AFD should regulate the distress caused by change (program
adoption), maintaining it within a tolerable range so that personnel can function and learn
(Heifetz & Linsky, 2002).
AFD Adaptive Leadership Challenges
Knowledge acquisition has been identified as the first step in generating awareness and
importance for a behavioral health program. The AFD recognizes the need to engage all
stakeholders, including firefighters of all ranks, in the process of change. Historically, one of the
critical barriers in the fire service is the stigma associated with seeking help. Therefore, the

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HWC needs to create a safe and trusting environment where firefighters feel comfortable sharing
their experiences because this feedback is crucial for program design and development. The
HWC will lead program development, but the entire organization needs to be mobilized for
systemic change rather than relying on a few individuals.
In conclusion, adaptive leadership provides a framework for addressing the complex
systemic challenges involved in implementing a behavioral health program in AFD. By
promoting engagement and resiliency, it offers a guide for creating meaningful and sustainable
change in high-stress environments.
Expectancy Value Theory
Expectancy value is a framework used to explain and predict attitudes and behaviors,
focusing on why individuals engage in specific tasks and how they motivate themselves to
pursue them (De Simone, 2015). Expectancy and value represent two primary components of the
theory. Expectancy refers to an individual’s acknowledgement of their ability to accomplish a
specific goal. They will be motivated to engage if they believe the goal is within their
capabilities. Value pertains to how much importance an individual attaches to the goal. Value is
represented by four components: intrinsic value, utility value, attainment value, and cost. The
theory submits that individuals are more likely to engage in and be motivated by challenges
when they expect to succeed and value the outcome. Within the AFD, the HWC can increase
firefighter’s expectancy by providing a curriculum on mental health, as it is relevant to future
goals within the department. Subsequently, the curriculum designed by the HWC should reflect
firefighters’ skills and abilities, enhancing both their expectancy of success and the value it adds
to increasing the individual’s overall health.

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Utility Value Theory
Utility value refers to the importance of engaging in a task and its correlation to
achieving broader goals. It influences how much value an individual attaches to completing such
a goal. When individuals assess an activity, they consider how completing this task will assist
them in achieving more significant objectives. Thus, the value of a mental health program must
fit into AFD’s current and future plans (Eccles & Wigfield, 2020). Utility value plays a vital role
in motivation because it helps individuals see the significance of challenging tasks. For example,
AFD personnel may not enjoy engaging in a mental health program. However, if they perceive
that program as crucial for future success, the value of engaging in it increases, motivating the
firefighter to invest the required effort. Anytown Fire Department personnel will likely prioritize
a mental health program if it encompasses higher value and aligns with their long-term goals. It
is essential to note the connection between intrinsic, attainment, and utility values. Intrinsic
associations revolve around the enjoyment an individual obtains from a particular task, while
attainment value reflects how the task is tied to the individual’s identity or personal standards
(Eccles & Wigfield, 2020). While both values have an intrinsically motivated origin, utility value
is more extrinsically focused, often in achieving future objectives.
HWC Utility Value of Mental Health Education
Utility value theory revolves around the idea of utility, which measures the satisfaction an
individual derives from a particular service (Hecht et al., 2021). Regarding a mental health
program, understanding the preferences, needs, and values of AFD personnel is vital. By
conducting interviews, the department can identify what aspects of mental health are most
important to its members and what support they value the most. Different mental health
interventions may have different perceived values among AFD personnel. For example, some

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may prefer clinical help, while others might find peer support networks more beneficial.
Grasping the value can help quantify these preferences to design a program that maximizes
overall satisfaction and effectiveness.
For AFD to be effective in its mental health interventions, conducting a cost-benefit
analysis is key. This involves comparing the utility or value of each intervention against its cost.
The objective is to allocate resources to interventions that provide the highest utility cost unit,
ensuring efficient use of department funds. However, due to budgetary restraints, not all services
can be implemented simultaneously. Identifying the value can ensure that the most valued and
impactful services are delivered first, making the most of the available resources.
By establishing metrics for utility, AFD can evaluate the effectiveness of the mental
health program. This can include measuring improvements in mental health outcomes, job
satisfaction, or decreases in sick callouts. These metrics can help the program evolve to
maximize its impact on AFD personnel. The HWC will actively seek feedback from firefighters
to make improvements to the program, as this is vital for the program’s responsiveness to
firefighters’ changing needs and its overall success.
Understanding the utility AFD personnel derive from participating in the mental health
program can also guide the development of incentive structures to encourage participation. For
example, if firefighters value recognition, the program might include acknowledgements or
rewards for consistent participation.
Utility value theory provides a framework for designing, implementing, and evaluating
AFD’s mental health program. Focusing on firefighters’ preferences, values, and satisfaction can
ensure the program is practical and efficient, leading to better mental health outcomes and
overall well-being for its members. Table 6 identifies two motivational influences: adaptive

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leadership and utility value. These influences will be employed to comprehensively analyze the
impact of motivation on HWC’s inclination to deliver health and wellness education for AFD.
Table 6
Motivation Influences
Assumed motivation influence Motivation influence assessment
Adaptive leadership
AFD needs to focus on how
they can effectively adapt to
and manage the complex
challenges related to the
mental and emotional wellbeing of firefighters
Interview: How can fire department leaders adapt their
leadership styles to better support the mental health needs
of their firefighters?
Expectancy value
AFD needs to clarify why they
pursue certain routes of
action and what they expect
as a result
Interview: Have you ever sought help from a fellow
firefighter?
Utility value
AFD needs to see the value in
educating firefighters about
behavioral health mitigation
strategies, starting in the fire
academy and continuing
through their career
Interview: How important is a new behavioral health
program to you? What value do you see?”

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Organizational Influences
Organizational influences set the tone for an organization by demonstrating how
individuals and groups work together to achieve higher level goals (Clark & Estes, 2008).
Examples of organization related performance gaps include the lack of efficient and effective
work process and material resources. Furthermore, more abstract factors such as organizational
culture can also have a significant impact on performance and performance improvement. All of
these contribute to the overall success of an initiative or change within an organization (Clark &
Estes, 2008).
Organizational Behavior Theory
Organizational influences that affect change are multifaceted and complex, encompassing
a broad spectrum of an organization’s structure, culture, and external environment. Organizations
intent on adaptive change will encounter culture as a fundamental component of the
transformation process (Heifetz & Linsky, 2009). Effectively addressing these influences is
essential for any organization to navigate change and achieve its strategic objectives.
Organizational behavior theory explores the interplay among individuals, groups, and structures
in organizational behavior. The collective values, beliefs, and norms within an organization
dictate the reception and integration of change initiatives. A culture that fosters innovation,
flexibility, and adaptability is more amenable to change than one characterized by rigidity and
resistance to new ideas.
In their analysis of organizational influences, Clark and Estes (2008) underscored the
significant impact of culture on both effectiveness and the capacity for organizational change.
They argued that organizational culture profoundly influences the implementation of change
initiatives and how members, such as firefighters, respond to these changes. The foundational

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core values and beliefs of the organization influence decision-making, set priorities, and shape
the behavior of individuals within the organization. Furthermore, the implicit rules governing
acceptable behavior within the organization play a pivotal role (Clark & Estes, 2008). These
norms influence how firefighters interact with each other and with the command staff, thereby
shaping daily operations.
Culture also plays a significant role in determining an organization’s openness to change.
Cultures that value flexibility, champion innovation, and encourage risk-taking are more likely to
embrace change effectively. Conversely, cultures that are risk-averse, rigid in processes, and
hierarchical tend to resist changes, thus impeding new initiatives’ success (Clark & Estes, 2008).
This underscores the need to foster a culture conducive to change, as it can either facilitate or
hinder change initiatives’ success.
An organization’s method of information dissemination is crucial during change
management. Transparent and open communication can build trust and facilitate smoother
transitions, whereas poor communication can foster misunderstandings and resistance.
Promoting a culture that supports continuous learning and development can address knowledge
gaps that hinder performance improvement. Such a culture enhances training efforts and
promotes knowledge sharing among firefighters, further supporting organizational change
initiatives.
HWC Explicit Influences for a Culture of Resiliency and Health
In the realm of firefighting, a culture that prioritizes valor and resiliency frequently
engenders a disinclination toward displaying vulnerability or seeking assistance for physical or
psychological health concerns. This embodiment of machismo can deter individuals from
acknowledging injuries or psychological distress, thereby intensifying health issues. Within the

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structured hierarchy of fire departments, such as the AFD, the necessity for discipline and
coordination during crises is undeniable. However, this rigid framework can sometimes hinder
open communication and the adoption of innovative practices. Additionally, this may precipitate
complications related to power dynamics and the potential for authority misuse.
Tradition is pivotal in the AFD ethos, often leading to resistance against integrating novel
methodologies, technologies, or procedural modifications that might enhance operational safety
and effectiveness. Moreover, the close-knit fabric of firefighting units like the AFD cultivates
deep interpersonal connections, and this solidarity can also exert pressure on individuals to
conform to established group norms and behaviors. This may foster behaviors like bullying or
the exclusion of members who are divergent or who contest conventional norms. These
dynamics within the firefighting culture necessitate a more nuanced understanding and approach
toward promoting behavioral health and organizational change.
The HWC was established to meet the specific health, and wellness demands of the AFD,
integrating services such as cardiac screenings, cancer testing, and the provision of peer fitness
trainers. Despite these advances, the HWC has not included a behavioral health component as
mandated by NFPA 1500, resulting in a significant gap within the organization’s health and
wellness program. This omission is critical, particularly as suicide rates surpass those of line-ofduty deaths, highlighting a pressing need for a comprehensive approach to address mental health
concerns within the AFD.
In response to these challenges, the FBHA is undertaking efforts to transform the fire
service culture to prioritize mental well-being. By offering various resources to enhance
accessibility to support services for firefighters, the FBHA also seeks to diminish the stigma
associated with seeking mental health care. Through these targeted initiatives, the FBHA aspires

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to cultivate a fire service environment that is increasingly responsive to and supportive of its
members’ mental health needs. This effort underscores the broader necessity of integrating
comprehensive mental health strategies into health and wellness programs within fire service
organizations. This study aims to examine the health and wellness culture within the AFD and
the HWC. Table 7 delineates three organizational factors crucial for AFD’s success. These
factors will be analyzed to assess their impact on the HWC’s capacity to formulate and
implement a comprehensive health and wellness program.
Table 7
Organizational Influences
Assumed organizational influence Organizational influence assessment
Organizational behavior theory: AFD
needs to examine the interplay between
individuals, groups, and structures that
lead to challenges in implementing a
behavioral health program.
Interview: What organizational barriers do you
perceive?
Cultural settings: AFD needs a culture
that promotes positive attitudes, beliefs,
and values regarding mental health.
Interview: Do you believe there are sufficient
behavioral health services for fire personnel?
Do you feel fire department cultural stigma forms
a barrier to seeking help for behavioral issues?

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Conceptual Framework: The Interplay of the HWC’s Knowledge, Motivation, and
Organizational Framework
A conceptual framework fulfills several critical roles in both scholarly research and
practical applications. It serves primarily to delineate the research questions, variables, and
methodologies for their examination. It offers a systematic methodology by articulating the
essential factors, constructs, and variables and positing the relationships among them.
Furthermore, a conceptual framework synthesizes a broad spectrum of concepts and theories
from the literature (Merriam & Tisdell, 2016). This synthesis facilitates the organization of these
theoretical frameworks, thereby providing a coherent structure that supports further study and
rigorous analysis.
Clark and Estes’s (2008) KMO influences framework presents a model for interpreting
the relationship between individual capabilities and organizational structures in shaping
performance, particularly within knowledge-intensive activities. Knowledge encompasses the
skills, expertise, and information firefighters possess or acquire. It is a fundamental aspect of a
firefighter’s capacity to execute tasks proficiently. Knowledge interfaces with motivation and
organizational influences by delineating a firefighter’s potential capabilities, impacting their
contribution to organizational objectives. The conceptual framework delineated here will
explicate a theory regarding the interaction dynamics of KMO overlays and their relationship
with one another. It will also delineate the modalities of interaction among local, state, and
national fire service entities within the broader domain of stakeholder objectives.
The HWC is influenced by the AFD and the aggregated expertise of state and national
bodies. Organizations such as the NFPA, FBHA, NFFF, and USFA establish guidelines and
protocols for mental health training and crisis management, which fire departments are mandated

68
to implement. These guidelines facilitate a uniform approach across diverse regions and
departments. For instance, the USFA provides training modules focused on the identification of
mental health crises, strategies for de-escalation, and protocols for engaging with individuals
experiencing mental health challenges. Through such educational initiatives, these agencies
equip firefighters to effectively address the mental health needs of the communities they serve
and their personal mental health concerns.
Figure 8 delineates four distinct stakeholders. The upper left quadrant illustrates nationallevel fire service institutions. Subsequently, the quadrant directly below it portrays the regional
(state) fire training academy. On the right side of Figure 8, a larger square symbolizes the AFD,
within which a smaller square is nested, representing the HWC. Arrows are represented as
emanating from both national and state regional squares toward the AFD and HWC squares to
illustrate the reciprocal influence exerted among these entities.

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Figure 8
Conceptual Framework for Influences on Behavioral Health Within the Fire Service
The state agency, exemplified by the regional fire training academy, provides firefighter
training courses to career and volunteer firefighters in Arizona, constituting the primary
educational resource available to these departments. The state training agency focuses on
professional education, certification testing, and evaluation of practical skills. Graphically, an
arrow originating from the regional fire training academy and pointing to the AFD and HWC
squares symbolizes this interactive relationship. In contrast, national fire service institutions
contribute by offering training and disseminating education that fosters best practices and shapes
the culture within the fire service. Arrows from these national institutions directed toward the
AFD visually represent this influential relationship.
The HWC was established within the AFD to foster a culture prioritizing health and
safety. A primary objective of the HWC is to develop and implement a comprehensive

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behavioral health curriculum for all AFD personnel. This initiative begins with annual
assessments and incorporates ongoing educational programs. At present, limited state or national
behavioral health courses are available. Mental health awareness classes have been conducted at
the national level but have not been integrated into the mandatory training protocols of the AFD.
Concurrently, even as national awareness of mental health has increased, there has been a
corresponding rise in behavioral health challenges, including suicide, burnout, compassion
fatigue, and PTSD. In response to these growing concerns, the HWC aims to create a robust
behavioral health curriculum.
Summary
Since 2014, suicides among firefighters have surpassed fatalities incurred in the line of
duty, signaling a persistent and escalating crisis. Scholarly research indicates a multifaceted
relationship between various factors, including occupational stress, substance abuse, PTSD, and
sleep deprivation, which collectively elevate the risk of suicides within this profession. In
response, the feasibility of implementing a behavioral health initiative as a preventive measure
against suicide among firefighters is under consideration.
This initiative will be scrutinized through a framework that assesses the interplay of
KMO influences that could foster or hinder its implementation. The research aims to identify the
barriers facing AFD in adopting this behavioral health initiative and determine the resources
necessary for its development. The methodology section of Chapter Three will present a more
detailed exploration of this analytical process.

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Chapter Three: Methodology
Firefighting is mentally and psychologically demanding, resulting in higher rates of sleep
disorders and behavioral factors contributing to suicide and suicidal ideations (IAFC & IAFF,
2018). Thirty percent of first responders develop challenges in mental health, compared to 20%
of the general population (Abbot et al., 2015). The literature suggests that the risk factors related
to suicide are manageable. Therefore, the purpose of this research is to understand why
behavioral health initiatives have not been incorporated into the wellness program at AFD. This
research strives to identify the pivotal knowledge, motivational, and organizational factors (Clark
& Estes, 2008) that contribute to or hinder the AFD in facilitating a behavioral health component
in the annual medical evaluation.
Research Questions
The following questions guided the gap analysis:
1. How do HWC describe the needs of a behavioral health program with AFD?
2. What are the key organizational barriers to the implementation of a behavioral health
program?
3. What strategies can be used to address the assessed needs of AFD concerning mental
health mitigation?
Overview of Design
This study used a singular approach utilizing qualitative research. Interviews represent a
source of accepted data that allows participants to share ideas freely without constraints from
predetermined instruments and scales (Creswell & Creswell, 2018). Triangulation of interviewee
responses constructs a contemporary propagation of themes (Creswell & Creswell, 2018) while
strengthening internal credibility and trustworthiness (Merriam, 1988). I conducted interviews in

72
person to evaluate KMO characteristics that impede AFD from consolidating a behavioral health
component into the health and wellness program. The interviews also helped inform what KMO
elements should be present to establish compliance. Qualitative research emphasizes the nature
of a particular phenomenon (Gibbs, 2018), and this research deploys an idiographic approach to
why AFD does not contain a behavioral health program and what components are needed to do
so.
Research Setting
For this research, the stakeholders were 10 HWC members within AFD. Interviewing the
HWC is crucial as they can integrate a behavioral health component into the health and wellness
program. Their roles and experiences are deeply embedded within the research context, making
them vital to interpreting behaviors, experiences, and perspectives relevant to the study’s
objectives. This study employed purposeful sampling, a form of non-probability sampling, which
enabled me to gain an understanding of specific cases (Patton, 2015) and align this
understanding with the research questions.
The recruitment strategy focused on 10 HWC members. The HWC is integral to
implementing and overseeing health and wellness programs within the department, making its
members critical stakeholders in the study. The target sample for the interviews was 10
participants. I selected this sample size to balance the depth and breadth of data collection. A
sample size of 10 is sufficient to achieve data saturation in qualitative research, where no new
theses or insights emerge from additional data collection. This number also enhances the
confidence factor and minimizes the margin of error, ensuring the reliability and validity of the
findings. To provide a comprehensive qualitative inquiry, I selected participants from various
ranks within the department, thereby capturing a diverse range of perspectives and experiences

73
(Creswell & Creswell, 2018). This approach aimed to capture a wide range of perspectives and
experiences, reflecting the hierarchical and functional diversity of the AFD. Including members
from different ranks ensured that the study encompasses the views of frontline personnel and
decision-makers.
Data collection methods consisted of interviews. An email was sent through the AFD
internal email system, discussing the purpose of the study and requesting participants. I selected
participants from the individuals who responded to the inquiry. The inclusion criteria were as
follows:
• AFD personnel: Fire Health & Wellness Committee members
• rank: At least two or more in each rank of chief officer, captain, and line personnel
• gender: At least one female participant among the 10, which is representative of the
overall workforce
I set up meetings for each participant. Each interview lasted approximately 45 minutes to
an hour and occurred in person. Informed consent was discussed and obtained at the beginning of
each interview. Data were produced from notes taken during the interviews. To ensure
trustworthy data, I used language clear to the respondent in each interview, and I was acutely
aware of potential preconceived relationships with the interviewee to remain neutral and not
shape responses with personal value judgements (Merriam & Tisdell, 2016). The participants
were reassured that all data would remain confidential.
The Researcher
To minimize bias, I conducted the research with integrity. Guidelines and policies from
governmental entities and institutions promote ethical conduct in research, although this conduct
comes down to one’s own ethics and value system (Merriam & Tisdell, 2016). A researcher must

74
remain conscious of positionality, so I avoided leading questions that support the desired
narrative. Instead, questions remained neutral and allowed the respondent to illustrate their world
through their lens. I hold a high-ranking position in my department and was cognizant of
individuals telling me what they thought I wanted to hear to be on my favorable side, thus
obscuring data. Assumptions are easy to make about the unknown, but that is one purpose of the
interview: to obtain the perspective of another in an area. This topic is an issue within the fire
industry, and there are multiple ideas for mitigating its adverse effects. This bias cannot be
interjected into the research because it distorts the data and influences participant responses. I
identify as a cis-gendered man, and the words I would use to describe an event are potentially
different from what a woman would use to describe the same phenomena. In this scenario, I used
member checks to confirm that her words were interpreted correctly (Merriam & Tisdell, 2016).
Data Collection
This study utilized one method as a primary qualitative data source. Interviews provided
an unstructured and open-ended approach that elicits specific views from the participants. This
helped me understand the research problem (Creswell & Creswell, 2018).
Interviews
I conducted 10 interviews in person. The interviews lasted between 45 minutes to 1 hour.
Qualitative research provides meanings with greater significance than frequencies (Pugsley,
2010), leading to an innate understanding of the problem under study (Creswell & Creswell,
2018). The interviews occurred outside the workplace to avoid external pressures that could have
obscured the data. The remote setting was also necessary to ensure privacy and confidentiality.
Allowing the interviewee to select his or her surroundings encouraged open dialogue and
reduced the vulnerability they may have felt in a location I had set.

75
I conducted this research using semi-structured interviews. A semi-structured approach
encouraged two-way dialogue that I could use to ask additional questions from respondents’
answers. The distinction of interviewing groups regarding age, gender, and rank allowed for a
broad spectrum of insight. The malleability of the semi-structured approach allowed the
interviewee to divulge information that was indirectly related to the questions. This elicited
themes that I had not initially considered.
The interview protocol consisted of open-ended questions acquired from literature on
KMO principles. The interview questions were constructed to understand the consequences of
the AFD’s lack of a behavioral health program. Responses were used to evaluate the
participant’s understanding of the organizational, motivational, and knowledge barriers to
improving mental health in their departments. This protocol enabled me to evaluate the
saturation of the interviews and determine when no additional insights were gathered. A sample
interview guide can be found in Appendix B.
Participants
The target population for the interviews was the HWC. The study centered on behavioral
health programs affecting mental health in the fire service, of which fire personnel need to be the
primary participants. The study utilized a semi-structured interview approach to explore ideas in
more detail while providing flexibility for discovering information previously unaccounted for
(Britten, 1995). The relationships built with firefighters yielded diverse responses that were
triangulated into common themes for analysis (Merriam & Tisdell, 2016).
The strategy for recruitment was to identify HWC members who agreed to voluntary
interviews. The HWC has the authority to implement a behavioral health component into the
AFD’s health and wellness program. The sample population for the interviews was 10 HWC

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members, as phenomenological research recommends a sample of five to 25 (Creswell, 1998).
The sample included representatives from different ranks, genders, and age groups.
Instrumentation
I conducted interviews through a semi-structured format, utilizing structured and less
structured questions. This approach allowed the interviewee to define their environments in their
own way (Merriam & Tisdell, 2016), illustrating a unique perspective. Additionally, this
approach allowed for steering the conversation in an exploratory path as innovative ideas surface
within the response (Merriam & Tisdell, 2016). The interviewing process is part of an emergent
design, structuring a plan for questioning that is not prescribed (Creswell & Creswell, 2018). The
interview framework consisted of 17 questions, separated by personal and organizational
categories. Clark and Estes’s (2008) KMO model influenced question design, focusing on
barriers within each category. The questions’ content allowed the respondents to discuss the
influences, factors, and individuals within their organization that have led to the development or
omission of behavioral health programs. The research questions focused on the gaps in
organizational practices that have contributed to shortcomings in providing a comprehensive
program for employee mental health. The KMO gap analysis model is used for the conceptual
framework to identify human causes of change and discern suitable solutions (Clark & Estes,
2008). The research questions and interview protocol exposed factors influencing goal
achievement, which may improve motivational urgency to allocate resources toward mental
health in the workplace.
Procedures
Data sources were interviews, which took place in the fall of 2024. Each interview was
45 minutes to an hour in length and occurred in person. Notes taken during the interviews

77
provided data. To ensure trustworthy data, I worded the questions with language clear to the
respondents. I was aware of a preconceived relationship with the interviewees and
comprehended the need to be neutral and not shape responses with value judgements (Merriam
& Tisdell, 2016). Additionally, I reassured the interviewees that all data would remain
confidential (Creswell & Creswell, 2018). I did not select participants directly under my
supervision to prevent a sense of obligation to participate and coined answers aligned with
perceptions of my perspective. Due to the sensitive topics discussed, I made resources available
to interviewees if they expressed any signs of distress or acute mental health crisis. Resources
included contact information for counselors trained in behavioral/mental health, such as AFD’s
licensed contracted counselor and other health care professionals with experience treating
firefighters.
Data Analysis
This study used a semi-structured approach to integrate qualitative evaluations of 10
interviews. I coded the interviews to identify themes and common characteristics within the data.
I performed data analysis between October and November 2024. I collected the interview data
through handwritten notes taken during the interview.
Credibility and Trustworthiness
I triangulated data to ensure credibility and trustworthiness. I interviewed individuals
from different ranks and genders to seek consistent themes. A second method to increase
credibility and trustworthiness is member checks, also known as respondent validation (Merriam
& Tisdell, 2016). After the interviews, I elicited feedback on the findings to ensure that there
were no misinterpretations. This is another strategy to reduce personal bias (Maxwell, 2013).
Proper engagement is critical to member checks. For example, I might use different words to

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describe the same event as the respondent, so I reconfirmed that I interpreted their words
correctly. A third strategy to ensure credibility and trustworthiness is adequate engagement in the
data collection. This strategy is centered on looking for alternative explanations to the data
findings (Patton, 2015). This was coupled with collecting more data and finding consistent
themes with slight variations. Failure to find supporting evidence of alternative explanations
adds to the credibility and trustworthiness of the initial findings. Initial evidence was a
hypothesis, and I used continued evaluation to find additional explanations.
Ethics
For the study to be received positively, I conducted the research with moral and ethical
integrity. Governmental organizations and institutions have multiple policies and procedures to
facilitate ethical conduct in research, which include a researcher’s ethics and value system
(Merriam & Tisdell, 2016). I knew my position and avoided asking leading questions that
supported my desired answers. Neutral questions better allowed the respondents to elaborate
freely in their answers. I am a high-ranking individual within my department, and any colleagues
interviewed (particularly those ranked below me) may have sought to respond agreeably to gain
favor in the workplace. Such bias in the interviewing would obscure the data. To mitigate this
risk, I strictly avoided language that provided value judgements and leading questions during the
interviews. I reassured each participant that all discussions would be de-identified and remain
anonymous for the study and that no workplace repercussions could result based on the
interviews.
Summary
The study utilized qualitative methodology to extract data from specific human subjects
with research backward. Interviewing was attractive because it allowed for an extraction of ideas

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from individuals in a particular setting, enriching the authenticity of the research. I conducted 10
interviews with individuals of differing backgrounds employed within the fire service. To protect
human subjects, I conducted this research to provide fire service options for developing
behavioral health programs while minimizing psycho-social harm to participants. The interview
questions assessed stakeholders’ ideas and perceptions about behavioral health programs in their
industry, facilitating an organic approach to inquiry. Due to the subjective nature of qualitative
analysis, peer review was necessary for the future review process. Subsequently, group thinking
can inadvertently influence peer review, which is why I sought individuals who do not think
along similar parameters. All qualitative research is interpreted through the researcher’s filter,
thus making researcher positionality a focal point to prevent personal conclusions from being
taken as universal constructs.

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Chapter Four: Results and Findings
This research sought a gap analysis focusing on the motivational, knowledge-based, and
organizational factors required for integrating a behavioral health curriculum into the AFD’s
health and wellness program. The gap analysis framework developed by Clark and Estes (2008)
was employed to assess AFD personnel’s needs, identifying obstacles to implementing
behavioral health initiatives. Additionally, Heifetz et al.’s (2002) adaptive leadership model was
applied to explore the foundations of organizational change. According to Heifetz et al. (2002),
standard operating guidelines, policies, and rules effectively address technical problems but must
be revised to resolve adaptive challenges. Consequently, I utilized Clark and Estes’ model (2008)
to pinpoint gaps in KMO resources. I also used the adaptive leadership model of Heifetz et al.
(2002) to categorize identified issues as either technical or adaptive, with each category requiring
distinct approaches for resolution.
I conducted a comprehensive literature review on behavioral health programs and
theoretical frameworks associated with KMO concepts. The review specified perceptions of the
knowledge, motivational, and organizational factors applicable to the AFD’s situation. This
chapter presents the influences identified, which informed an understanding of the motivational,
organizational, and knowledge-related requirements needed to address barriers in the design and
implementation of the behavioral health program. I conducted interviews with 10 AFD members,
who agreed to participate on the condition of anonymity. I evaluated each of the influences to
determine whether it was an asset or need for AFD. The criteria for determining whether an
influence was an asset or need was agreement among the interviewees. If at least 60% of
respondents identified an influence as being missing from AFD’s existing resources and having a
potential benefit, then the influence was determined to be a need as opposed to an existing asset.

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The AFD interviews began in August 2024 and were completed by the end of September
2024. Participants elected against being recorded, as they requested anonymity as a stipulation to
being interviewed. The AFD experienced line-of-duty deaths in Spring 2022 and Summer 2023,
both of which had an unfavorable impact on the department. After months of internal
investigations, persistent discontent with the department’s command staff remains evident and
may have contributed to the participants’ penchant for anonymity. The following research
questions facilitated this study:
1. How do the HWC describe the needs of a behavioral health program with AFD?
2. What are the key organizational barriers to the implementation of a behavioral health
program?
3. What strategies can be used to address the assessed needs of AFD concerning mental
health mitigation?
Appendix C shares the specific questions posed to each study participant.
Participants
All interviewees are employed by the AFD and members of the HWC. Table 8 lists the
interviewees’ demographics. Of the 10 interviewees, one (10%) was female, and nine (90%)
were male. The sample included four (40%) Native American participants and six (60%) nonNative American participants. In terms of experience, five (50%) had 10 to 19 years of service,
four (40%) had 20 to 29 years, and one (10%) had 30 or more years of service. Regarding age
distribution, two participants (20%) were aged 20–29, two (20%) were aged 30–39, one (10%)
was aged 40–49 and five (50%) were aged 50–59. Throughout the analysis of the interview data
for KMO influences, the participants will be identified using numbers one through 10 (i.e.,
Interviewee 1).

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Table 8
Interviewee Demographics
Interviewee Sex Career fire dept Nationality Age group Service length
1 M Yes Native 50–59 30+ years
2 M Yes Non-Native 50–59 20–29 years
3 M Yes Non-Native 30–39 10–19 years
4 M Yes Native 50–59 20–29 years
5 M Yes Non-Native 20–29 10–19 years
6 M Yes Native 40–49 10–19 years
7 F Yes Non-Native 50–59 20–29 years
8 M Yes Non-Native 50–59 20–29 years
9 M Yes Native 30–39 10–19 years
10 M Yes Non-Native 20–29 10–19 years
Determination of Assets and Needs
Assets refer to resources that AFD already possesses, such as yearly medical evaluations.
Assets focus on building up the department’s strengths, which can lead to sustainable progressive
changes. Alternatively, a need refers to an element needed to meet the community’s needs while
facilitating the optimal AFD function. This study utilized interviews as a data source to collect
the views of firefighters needed to close the performance gap related to developing a behavioral
health program (Clark & Estes, 2008). The interviews were analyzed to determine the assets and
needs of the assumed influences. I examined the participants’ responses to determine their KMO
influences regarding behavioral health at work and the feasibility of implementing a behavioral
health program. Table 9 lists the assumed influences. I evaluated each influence to determine
whether it was an asset or need for AFD. The criteria for determining whether an influence was

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an asset or need was agreement among the interviewees, with at least 60% of respondents being
required to designate an influence as a need.
Table 9
KMO Influences Analyzed
Knowledge Motivation Organization
Factual Adaptive leadership Organizational behavioral theory
Conceptual Expectancy value theory Cultural settings
Procedural Utility value theory
Metacognitive

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Results and Findings for Knowledge Causes
This section examines the knowledge categories for each related influence discussed in
the conceptual framework outlined in Chapter Two (Table 5). These include the factual,
conceptual, procedural, and metacognitive influences identified from the data analysis.
Conventional qualitative analysis relies on identifying themes from research and then
triangulating the phenomenon into interpretation by the researcher. Building off the data to
examine the themes and the value of assumed influences is integral to this research. Interviews
provided the opportunity to clarify the study and augment remarks with additional questions. The
data assisted in determining the assumed influences associated with behavioral health stressors
and the potential role a behavioral health program could play in AFD.
Factual Knowledge: Influence 1
I asked the interviewees, “Outside of the employee assistance program (EAP), are there
any behavioral health services available to you?” (Question 12 from the interview protocol). The
purpose of this inquiry is to elicit factual, or declarative, knowledge. As discussed previously,
factual knowledge refers to the “know what” aspect of information. In this situation, a response
in the negative (meaning the interviewee was not aware of any additional services) was
considered to establish this influence as a need rather than an asset at AFD. As 70% of
interviewees responded that they had no knowledge of additional resources, this qualified as a
need. Furthermore, multiple respondents indicated that they were not aware of the services
provided by EAP. Interviewee 5 noted, “I’ve seen an ad for EAP in a bathroom stall, but I have
no idea what they actually do.”
As discussed in Chapter Two, the recent U.S. Fire Administrator’s Summit on Fire
Prevention and Control identified behavioral health as one of six critical issues affecting the

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current state of the fire service. Despite this, 73% of all fire departments in the United States lack
a behavioral health program (NFPA, 2021). It remains to be seen how the 27% of U.S. fire
departments with such programs educate and train their personnel. The AFD has not established
any initial or ongoing behavioral health education for its personnel.
Conceptual Knowledge: Influence 2
I asked the interviewees, “What do you think should be included in a fire department
behavior health program?” (Question 4 on the interview protocol). This influence is an example
of conceptual knowledge. Conceptual knowledge refers to a comprehension of complicated ideas
and systems. It involves grasping fundamental principles and often abstract concepts. This type
of knowledge goes beyond factual or declarative knowledge and beyond how to do things
(procedural knowledge). Conceptual knowledge is about linking various pieces of knowledge
together (Schneider et al., 2011). With this question, I asked the interviewees to explore what
systems and services could potentially enhance mental health at AFD. Interviewee 9 responded,
If [command staff] cared, they would be creative in how they approached mental health.
We could use telemedicine with public safety psychologists. And they need to be public
safety. You think I’m gonna talk to some therapist that deals with couples in real estate
and whatnot? Hell no. We need someone relatable. How about having a station dog? I
know other agencies do it. And routine quarterly psychological meetings. We should add
mental health to our annual physicals. Command staff needs to step up and take care for
their people.
Seven other interviewees responded in kind by suggesting various initiatives and
measures for a behavioral health program (total of 80% of interviewees), thus identifying this as
a departmental need. The AFD needs to recognize that prioritizing firefighters’ mental health is

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as critical as emergency response. It is clear that the interviewees have expectations that the
organization is not meeting.
Procedural Knowledge: Influence 3
I asked the interviews, “Are you satisfied with your department’s managing of stress
management?” (Question 7 on the interview protocol). This is an example of eliciting procedural
knowledge, or the know-how aspect involving skills and processes (Hurrell, 2021). Processes
such as pulling fire hose or the more complex critical incident stress debriefing are all activities
that require a stepwise approach for consistency and quality assurance. When answering this
question, the interviewees expressed an understanding of the department’s current approach to
stress management.
Ninety percent of the interviewees indicated that they were not satisfied with the
department’s managing of stress management. This constituted an overall need for the
department rather than an asset. Interviewee 8 commented, “The current management strategy
for stress management is to ignore it. Wait until something catastrophic happens, like a DUI or
an on-duty death due to drug overdose like we had last spring. Then, ignore it some more.”
Interviewee 6 echoed this sentiment and stated,
We had one of our guys die from getting high on duty, and not a thing has changed. Zero
uptick in mentions of substance or alcohol abuse [and] no outreach from leadership to
prevent something like this from happening tomorrow or the next day.
In contrast, Interviewee 10 denied dissatisfaction with the current procedures for
managing stress among firefighters. “I have no idea what they do for stress management. I’ve
never asked for help, but I’m sure they will do something if you do. How can I be mad at them
for that?” Aside from this individual, who seemed ambivalent about leadership in this area at

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best, others were quite clear in their view that the procedural knowledge of how leadership
manages stress among firefighters is severely lacking. The lack of weight given to this issue
concerned them greatly as it seemed to set them up for failure.
Metacognitive Knowledge: Influence 4
I asked the interviewees, “Do you feel your stress as a firefighter has caused unresolved
psychological/emotional issues?” (Question 6 on the interview protocol). This question sought to
elicit metacognitive knowledge from the respondents. Metacognitive knowledge involves an
awareness and understanding of one’s thought processes, including how one thinks, learns, and
solves problems. For example, metacognitive knowledge encompasses the way in which a
firefighter understands his or her beliefs and how they shape his or her attitudes toward
behavioral health.
This was the only interview question in which 100% of interviewees agreed. Each
participant responded in the affirmative: stress as a firefighter caused unresolved psychological
or emotional issues. Interviewee 8 described feeling isolated in his interpersonal relationships
because of his career:
My ex-wife never understood why I was on edge all the time. I tried explaining to her
what it was like to be on duty for 72 hours straight and dreading getting a bad call: kids
are the worst. Spending fully a third of your nights in a state of half wakefulness on one
of the crappiest mattresses you can imagine. You can’t turn that off when you get home.
By the time I finally unwind mentally, it’s time to go back to work.
Interviewee 4 discussed his history of alcohol abuse:
I drank when I was in the military, but nothing like I was doing here. Drinking is part of
the culture in the fire department. We celebrate with alcohol, and we de-stress with

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alcohol. It took me years to get sober, and now I barely spend any time with the other
guys outside of work because I don’t want to be around that culture anymore.
Interviewee 7 explained,
What we see on the job can haunt you for years. Decades ago, when I was just an EMT
and applying as a firefighter, we had this call for a one-vehicle collision. When we
arrived, we were able to get the driver, who was drunk, out of the driver’s seat. The car
was on fire, and we didn’t realize there was a baby in the back seat until it started
screaming. We couldn’t get it out in time; we didn’t have the equipment as EMTs.
There’s nothing in the world like the sound of a child as it’s burning to death. I’ll be able
to hear that sound in my head until the day I die.
She added,
A few years later, when I had my own kids, sometimes the sound of their cries or screams
would take me back to that awful night. I would break out in a sweat and feel panicked
and helpless all at once. But I had to keep going. I haven’t talked to anyone about that
call in years.
Each interviewee identified one or more examples of unresolved psychological or
emotional issues. This is a demonstration of metacognitive knowledge of their thought processes
and reactions to their daily experiences in the fire service. The overwhelming burden involved
with their day-to-day operations indicates that behavioral health support is a departmental need,
not a current asset. The pervasiveness and diversity of stressors related to working in the fire
service call for a comprehensive, thoughtful intervention at multiple levels in the department.
Table 10 summarizes the findings of the four knowledge-related influences. All four
knowledge-related influences (factual, conceptual, procedural, and metacognitive) were

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determined to be departmental needs through analyzing the interviews. At least 60% of the
interviewees agreed that each influence was lacking from AFD’s current resources. Chapter Five
discusses recommendations regarding knowledge-related interventions.
Table 10
Knowledge Assets or Needs As Determined by the Data
Assumed influence and interview item Response category Asset or need
Factual: Outside of EAP, are there any
behavioral health services available
to you?
Response of no → need (70%)
Response of yes → asset (30%)
Need
Conceptual: What do you think should
be included in a fire department
behavior health program?
Response that includes suggestions
→ need (80%)
Response expressing satisfaction
with current services → Asset
(20%)
Need
Procedural: Are you satisfied with your
department’s managing of stress
management?
Response of no → need (90%)
Response of yes → asset (10%)
Need
Metacognitive: Do you feel your stress
as a firefighter has caused unresolved
psychological/emotional issues?
Response of yes → need (100%)
Response of no → asset (0%)
Need
Note. If 60% or more of interviewees identified an influence as a need, this was considered a
departmental need for AFD.

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Results and Findings for Motivation Causes
This section examines the motivation-related influences discussed in the conceptual
framework outlined in Chapter Two (Table 6). These include adaptive leadership, expectancy
value, and utility value influences identified from the interview data. The interviews helped to
identify the motivation-related influences and determine whether each influence was a
departmental asset or need. Motivation is a critical force in driving employee performance and
organizational success. It is the degree to which employees are willing to engage with their work
and exert effort toward achieving organizational goals (Clark & Estes, 2008). Identifying gaps
between an employee’s current motivational state and the optimal state needed to achieve a high
level of performance. This gap analysis will assist in creating recommendations for improving
performance, which will be discussed in Chapter Five.
Adaptive Leadership: Influence 5
I asked the interviewees, “Do you believe increased behavioral health awareness in the
fire service will lead to more resources being distributed to address these issues?” (Question 17
on the interview protocol). This inquiry sought to elicit the interviewee’s views on whether AFD
follows an adaptive leadership model and, if so, how successfully. Adaptive leadership is a
framework that assists individuals and organizations in adapting to challenges that are identified
as either technical problems or adaptive challenges. It is particularly effective in situations in
which innovation and learning are needed (Heifetz et al., 2002). As AFD currently has no
behavioral health component to its education and training, adaptive leadership is an ideal
strategy.

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Sixty percent of interviewees responded that they believed an increase in behavioral
health awareness in the fire service would lead to more resources being distributed to address
these issues within AFD. Interviewee 2 said,
Maybe if guys keep offing themselves, and it makes the news often enough, someone in
command staff will finally pay attention. We’re lucky we haven’t had that here, but one
of our guys OD’d, and that’s almost the same. An accidental suicide, if you will.
Interviewee 6 expressed a similar sentiment, relating:
We hear about behavioral health problems and suicide in the fire service way more now
than we used to. I can see them starting to do something about it here in the next couple
of years. Leadership loves buzzwords, and unlike most departments, we have money to
spend.
Historically, the fire service is known for emergency response and public safety. Even
today, most of AFD’s budget is spent on emergency equipment to serve external customers. In
the hierarchy of needs, mental health is not prioritized, even as reported cases of mental health
issues continue to rise in the fire service. The remaining 40% of interviewees expressed
pessimism regarding any resultant action by leadership. Interviewee 9 specified,
We are not a priority to [command staff]. We work 24-hour shifts away from our family
and they act like it’s an expectation. No thanks or gratitude. When we have problems, we
deal with them ourselves. I don’t trust admin staff. I know a lot of departments are trying
to get a program running, but everyone is out for themselves here. I don’t see it
happening, just talk.

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When firefighters feel they are not prioritized, they start to question their purpose in the
organization, and resentment builds up, increasing the feeling of ostracization that already
accompanies those struggling with mental health.
Expectancy Value: Influence 6
I asked the interviewees, “Have you ever sought help from a fellow firefighter?”
(Question 13 on the interview protocol). This question sought to evaluate their perspective in
relation to expectancy value. Expectancy value is a framework used to explain and predict
attitudes and behaviors, focusing on why individuals engage in certain tasks and how they selfmotivate to pursue those tasks (De Simone, 2015). “Expectancy” refers to an individual’s
acknowledgement of their ability to accomplish a specific goal. “Value” pertains to the amount
of importance the individual attaches to the goal. The theory posits that individuals are more
likely to engage in and be motivated by tasks when they expect to succeed and value the
outcome. In the context of this interview question, I asked the participants to consider their
expectations of what a peer could offer in the way of support, as well as the value of that support.
Interviewee 2 stated,
People compartmentalize a lot of issues; they work within their small groups because
they don’t believe those above them will do anything. If there was trust that the
information would not be used against us, it could be a solid thing. I know we have talked
about it before.
This promotion reflects a desire to delve deeper into the subject, which could involve
researching best practices, learning from regional fire departments, engaging with behavioral
health professionals, or conducting needs assessments among AFD personnel. It also suggests
that the participants are motivated to bridge the gap between their current understanding and

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program implementation, emphasizing training, collaboration, and resource development to
effectively address AFD’s behavioral health needs. Interviewee 5 said, “We need someone
spiritual to guide those in need, religious is okay too. We don’t have trust; we need a mentorship
program.”
Utility Value: Influence 7
I asked the interviewees, “How important is a new behavioral health program to you?
What value do you see?” (Question 9 on the interview protocol). This question seeks to examine
motivation in the context of utility value. Utility value refers to the importance of engaging in a
task and its potential to aid in achieving broader goals. This affects how much value an
individual attaches to completing the goal. In relation to the question, I asked the participants to
assess the utility they would receive from a novel behavioral health program and the overall
importance of that utility.
Despite the limited actualization of their knowledge, participants recognized the
importance of behavioral health and advocated for further investigation into how the AFD can
develop a comprehensive program. Interviewee 1 felt the emphasis on mental health is just
starting to arise, and that is why the department is slow to orchestrate a formal behavioral health
program:
New concept. Physicals are usually anatomy and physiology, not mental health. When I
came into this field, we didn’t talk about mental health. But lately, you hear people talk
and more and more about it, usually the younger generation. They are just built
differently. I think they come out of the academy softer than when I went through.
In contrast, 20% of interviewees did not see value in the addition of a behavioral health
program (Table 11). This response could be due to a variety of factors, such as a lack of formal

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training on behavioral health, insufficient exposure to existing behavioral health frameworks, or
gaps in the organizational structure to support knowledge implementation. Interviewee 4 stated,
Mental health is a buzzword. It’s too late for us older guys. The damage is done. You
can’t reverse what I’ve seen. A mental health program is not needed because it won’t
have that much of an effect for us that have been here awhile. Maybe the younger
generation feels differently.
The participants might understand the need for behavioral health initiatives in theory but lack the
expertise to turn that understanding into a program.
Table 11
Motivation Assets or Needs As Determined by the Data
Assumed influence and interview item Response category Asset or need
Adaptive leadership: Do you believe
increased behavioral health
awareness in the fire service will lead
to more resources being distributed
to address these issues?
Response of yes → need (60%)
Response of no → asset (40%)
Need
Expectancy value: Have you ever
sought help from a fellow
firefighter?
Response of yes → asset (30%)
Response of no → need (70%)
Need
Utility value: How important is a new
behavioral health program to you?
What value do you see?
Response indicating positive value
→ need (80%)
Response indicating negative or no
value → asset (20%)
Need
Note. If 60% or more of interviewees identified an influence as a need, this was considered a
departmental need for AFD

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Results and Findings for Organizational Causes
This section examines the organizational-related influences discussed in the conceptual
framework outlined in Chapter Two (Table 7). These include the organizational behavior theory
and cultural setting influences identified from the interview data. The interviews helped to
identify the organizational-related influences and determine whether each influence was a
departmental asset or need. Organizational influences are vital for individual and organizational
performance, as they provide a conscious and unconscious understanding of our values and how
they play into our work behavior (Clark & Estes, 2008). Learning as an organization requires
someone’s original values and beliefs to be adopted over time (Schein, 2017), but the efficacy of
such beliefs is confirmed through shared experiences.
Firefighters often share experiences from working in close-knit teams during high-stress
situations, often involving risk and sacrifice. Over time, this behavior shapes the organization’s
culture as it builds up resiliency in response to workplace challenges (Clark & Estes, 2008).
These response mechanisms become normalized, creating a culture that provides stability within
a chaotic environment. The desire for organizational growth creates tension between stability and
change (Clark & Estes, 2008), resulting in a reluctance to deviate from organizational norms
(Burke, 2018). Identifying organizational gaps between work processes and goal attainment is
key to enhancing the collective understanding of how the policies and behaviors are effective in
closing the performance gap. This gap analysis will assist in creating recommendations for
improving performance, which will be discussed in Chapter Five.
Organizational Behavior Theory: Influence 8
I asked the interviewees, “What organizational barriers do you perceive?” (Question 15
on the interview protocol). This question sought to elucidate organizational factors that

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contribute to the lack of behavioral health care awareness and treatment at AFD. Organizational
behavior theory examines the interplay among individuals, groups, and structures in
organizational behavior. The success of change initiatives depends on the collective values,
beliefs, and norms within an organization. In this situation, culture and existing structure
Eighty percent of the interviewees indicated that there were one or more organizational
barriers at play at AFD. I interpreted this as being an organizational need or an area for
improvement. Multiple individuals commented that the culture of the department and the fire
service at large is resistant to change. According to the literature review in Chapter Two,
firefighters face cultural barriers to mental health that include embarrassment from co-workers
on the condition, a fear of being ostracized or shunned for future promotions, and a chronic
stigma of not being a fit firefighter. Others discussed their experiences with mental health, how
the department culture impacted their desire for transparency, and how the department leadership
failed to meet their expectations.
Multiple respondents distinguished cultural barriers influencing behavioral and mental
health. Interviewee 4 stated,
I hit a point where I had suicidal ideations. I was having issues with PTSD and conflict at
work. Eventually, I used an assistance program through the military because I didn’t trust
anyone I worked with. Senior staff was brought into their ranks with little mentorship,
leading to them not knowing how to handle mental health in people.
Expanding on cultural barriers, Interviewee 6 indicated,
My wife didn’t even know she had access to assistance when I was overseas. Lack of
knowledge. Nobody contacted my family to see if they needed help when I was gone. I

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came back, and people started calling me “brother” and shit. That pissed me off because
it was the furthest from the truth.
These clarifications may explain why cultural barriers were the most common topic mentioned
during interviews.
Five of the 10 participants commented on the lack of literature disseminated by the
department on mental health. Interviewee 10 referenced how the department has committees to
spearhead any new programs, but he has not seen anything from the HWC on behavioral health
programs:
I was hearing about a mental health initiative but never saw anything in my email. When
I hear about these rumors and then nothing comes of it, I think the department is not
serious about it and just wants to say they are doing something just to appear proactive.
We follow other departments on things, and it seems we are the last to make any changes,
so I felt let down because mental health is very important, but I guess not to everyone.
Interviewee 10 represents a younger demographic who wants the department to be more
aggressive in mitigating the mental aspects of the job. Interviewee 10 continued,
I would expect the command staff to take this seriously and have the framework laid out,
similar to when we change any piece of equipment. We have in-house training on the
new piece of equipment, including dialogue on why we are changing and how it’s going
to benefit us. Any program in the department should follow that structure. Just because
UL and NIOSH haven’t published studies on mental health doesn’t mean the research
isn’t out there.
Therefore, AFD is creating less buy-in if they fail to orchestrate the same program framework
with data-driven research, similar to other department programs.

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Even though participants demonstrated limited knowledge actualization, meaning they
still need to translate their understanding of behavioral health into tangible initiatives, they
expressed an understanding of the need for such programs. Inadequate behavioral health training,
a lack of urgency from senior staff, and organizational barriers are contributing factors to
inhibiting program development.
Cultural Settings: Influence 9
I asked the interviewees, “Do you believe there is sufficient behavioral health services for
fire personnel?” (Question 16 on the interview protocol). This question sought to examine the
interviewees’ understanding of the cultural setting at AFD and its impact. A cultural setting is a
visible location where policies, practices, and groups of individuals come together to accomplish
an intersecting goal (Gallimore & Goldenberg, 2001).
Stakeholder engagement is vital for the creation and sustainability of a behavioral health
program. Without utilizing the resources outside of the department, the program will struggle to
be a success. Interviewee 8 said,
Why don’t we get Heart Fit on board? They have doctors, nurses, PA’s and we already
contract with them so it would make sense to see what they can offer us. The hardest part
of opening up to someone is there is no rapport with that person and a sense of
vulnerability prevents us from opening up. Since we have already built rapport with that
company, I think it would be a valid option. Better yet, why don’t we put one on staff
here? That way, we could speak with them on and off duty.
Many of these external stakeholders are serviced by firefighters in their jurisdiction. They would
have a vested interest in the success of a behavioral health program. A benefit of utilizing mental
health professionals is their use of evidence-based research and best practices. The AFD has

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limited knowledge of the best practices for behavioral health, and mental health professionals
could provide insights into training design and implementation. Subsequently, AFD would use
the behavioral health program to funnel evidence-based research to fire personnel, which may
increase buy-in at all ranks.
Cultural Settings: Influence 10
I asked the interviewees, “Do you feel fire department cultural stigma forms a barrier to
seeking help for behavioral issues?” (Question 8 on the interview protocol). This is another
question that sought to clarify the cultural setting and potential organizational barriers therein.
Firefighters are expected to be physically and emotionally resilient, often portraying an image of
toughness and rigidity. This image influences how they want to be perceived by others, including
fellow firefighters. Projecting this image can make firefighters reluctant to ask for help, as they
want to appear strong and competent. This environment can generate hindrances to seeking
mental health assistance, as firefighters often face cultural norms that discourage vulnerability
(Jones et al., 2020). Specifically, the social customs within the fire service may suppress
emotional expression, as displays of emotional sensitivity are often perceived as signs of
weakness (Thurnell-Read & Parker, 2008).
The interview analysis reveals the significant impact that culture has in shaping behavior
related to mental health in the AFD. Ninety percent of interviewees responded that cultural
stigma was a barrier to seeking help for behavioral issues, indicating a departmental need for
improvement rather than an asset. The negative stereotypes propagated by department culture
may be a reason for the continual increase in mental health issues and a barrier to program
development. Through the interviews, two key themes emerged in response to this research
question: the influence of department culture and organizational priorities.

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The participants revealed themes that outline challenges with department culture and
prioritization of mental health. Fears of cultural stigma led firefighters to seek assistance from
other organizations outside of the fire department. Subsequently, the department preaches
brotherhood and sisterhood to its members but fails to recognize that cultural components are not
embraced in AFD, leading firefighters to expectations of security that are not being met.
Analysis of interviews revealed a lack of evidence-based practices for behavioral health
and a need for increased stakeholder engagement. Change in the fire service is difficult, but
when it occurs, it is guided by evidence-based research. Studies from federal agencies like the
National Fire Academy and private companies such as UL and NIST provide the motivation
needed for fire agencies to buy into the change. An evidence-based approach could increase the
motivation for AFD to develop a behavioral health program while tying in with outside
stakeholders. The interviews have identified areas for initiatives, such as awareness training in
the fire academy, a mental health component added to the annual physical, and getting a station
dog. Without external stakeholders, these ideas will not come to fruition, so their incorporation
into the program’s development is imperative. Additionally, without speaking to these agencies,
AFD cannot comprehend the extent of their services, which may provide solutions currently
unknown.
Historically, one of the critical barriers in the fire service is the stigma associated with
seeking help. Therefore, the AFD needs to create a safe and trusting environment where
firefighters feel comfortable sharing their experiences because this feedback is crucial for
program design and development. The participants revealed how buy-in is achieved more
efficiently through evidence-based research and stakeholder engagement (Table 12). Utilizing
outside resources like mental health professionals can expand the scope of resources for

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behavioral health development and implementation. Evidence-based research is a framework
utilized by the department to influence change in all other areas, so why not in mental health?
Table 12
Organizational Assets or Needs As Determined by the Data
Assumed influence and interview item Response category Asset or need
Organizational behavior theory: What
organizational barriers do you
perceive?
Response identifies barriers →
need (80%)
Response does not identify barriers
→ asset (20%)
Need
Cultural settings: Do you believe there
is sufficient behavioral health
services for fire personnel?
Response of yes → asset (30%)
Response of no → need (70%)
Need
Cultural settings: Do you feel fire
department cultural stigma forms a
barrier to seeking help for behavioral
issues?
Response of yes → need (90%)
Response of no → asset (10%)
Need
Note. If 60% or more of interviewees identified an influence as a need, this was considered a
departmental need for AFD.

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Summary
The interview results revealed a general lack of awareness regarding the factors affecting
mental and behavioral health in the fire service, as none of the respondents (0%) identified
compassion fatigue or burnout as significant issues. Participants noted that the AFD does not
have a behavioral health program and is not in compliance with NFPA 1500 standards. However,
several key themes emerged from the triangulation of the interview data. The most prevalent
theme was a lack of trust in the department’s command staff, which was repeatedly highlighted.
The command staff plays a highly influential role and may represent the cultural barriers
identified by multiple interviewees.
A recurring suggestion among participants was incorporating a behavioral health
component into the department’s annual physical assessments. Additionally, many interviewees
emphasized the need for department officers to be trained in interpersonal dynamics. The data
further indicated that AFD has historically not prioritized mental health, often opting to address
such issues at the lowest possible level. According to interviewees, there is an intense desire
among AFD personnel for a comprehensive behavioral health program with recurring, annual
components fully supported by the department’s command staff. Interviewees made a
compelling case for extending access to behavioral and mental health education beyond active
firefighters. They recommended that such education be made available to firefighters’ families
and retired personnel, recognizing the significant impact of these issues on the broader fire
service community. Another frequently mentioned suggestion was the need to emphasize
behavioral health education during firefighter training at the academy, throughout their careers,
and into retirement.

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Chapter Five: Recommendations and Evaluation
The purpose of this project was to conduct a gap analysis in the KMO areas to create a
behavioral health component of AFD’s HWC. The study used Clark and Estes’ (2008)
framework to identify the needs and assets of AFD. The analysis was performed by interviewing
10 members of AFD of varying age, career length, and sex. I used the data to identify
departmental assets or needs. The following questions guided this study:
1. How do HWC describe the needs of a behavioral health program with AFD?
2. What are the key organizational barriers to the implementation of a behavioral health
program?
3. What strategies can be used to address the assessed needs of AFD concerning mental
health mitigation?
The following sections will examine the recommendations and evaluation process for
addressing these challenges as determined by the data analysis results and informed by the
literature.
Recommendations to Address Knowledge, Motivation, and Organization Influences
Clark and Estes’s (2008) gap analysis framework assists in identifying obstacles to
organizational change and performance improvement. It is based on the concept that
performance issues can be traced back to a deficiency in one or more of the categories of KMO
influences. Analyzing an organization through this lens allows for a thorough and multi-level
approach. After identifying these influences, targeted interventions can be developed to address
each influence individually. The overall effect is a broad study and plan of action.
All study participants expressed an understanding of the need for behavioral health
training. The negative consequences of mental health in the fire service have been reported

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throughout the region, and this has shaped interviewees’ desire for additional training. The HWC
was established to meet the specific health and wellness demands of the AFD but has not
included a behavioral health component. It would be inaccurate to say the organization has yet to
achieve its goals because no goals are associated with a program that does not exist.
The task of AFD’s behavioral health program is to provide firefighters with the
knowledge, skills, and abilities to manage the stress from routine job duties that influence
detrimental behaviors, leading to healthier lives. Trends in mental health can be identified, and
this information will influence policy and help mitigate future challenges. Program facilitation
can be accomplished through a coordinated effort among department resources to normalize
mental health and encourage the command staff to support behavioral health initiatives. The
following sections contain recommendations to address the KMO influences that impact the
development and implementation of a behavioral health program within AFD. Each section will
include aggregated factors supported by data collection and rooted in pertinent literature.
Knowledge Recommendations
Knowledge provides the basis upon which to make decisions, both at the individual and
organizational level. Accurate, comprehensive knowledge is essential for successful decisionmaking. I identified four knowledge influences based on the interview data. Each indicates a
departmental need for intervention. Table 10 summarizes the data analysis related to knowledge
influences. This table represents the validated needs based on the interviews.
Factual and Conceptual Knowledge Solution
Provide firefighters with a visual learning tool (job aid) that charts behavioral health
resources available to them. The results and findings illustrated a need for factual knowledge
about the mental health resources available to firefighters outside the community’s EAP.

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Cognitive load theory can be applied to make recommendations. Sweller (1988) discussed the
effectiveness of how information is processed and transferred to long-term memory, increasing
the organization of the material. In careers like firefighting, cognitive overload is a byproduct of
the high-stress environment, inhibiting knowledge from being stored in long-term memory. This
suggests that firefighters would benefit from visual learning tools like job aids. Thus, the
recommendation is to provide firefighters with a visual learning tool (job aids) outlining
available resources for firefighter mental health, both inside and outside the department. Since
firefighters need to be proactive in finding resources for mental health, job aids provide a
framework to accomplish this goal on their own (Clark & Estes, 2008).
According to Jean Piaget (Wadsworth, 1976), a schema is a cognitive framework that
assists individuals with interpreting and organizing knowledge. Consequently, disseminating a
visual aid showing resources available for firefighter mental health can assist firefighters with
retaining the information. Schemas stress the importance of prior knowledge to learning
(Merriam et al., 2007) and use memory (visual) aids to link prior knowledge to new knowledge,
making it easier to retrieve. The recommendation is to provide a memory aid that helps
firefighters recall knowledge of mental health resources and highlight risk factors like suicide,
compassion fatigue, burnout, PTSD, and substance abuse, which were identified in the literature
as issues for firefighters. Visual aids can be placed under firefighter helmets, on the back of their
ID cards, or in a common area within the fire station.
Procedural Knowledge Solution
I recommend providing awareness training with coaching that involves skills and
processes on strategies for stress management. Procedural knowledge refers to the information
about how and when to perform tasks (Clark & Estes, 2008). The results and findings illustrated

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a need for procedural knowledge on stress mitigation tactics, specifically guidance on how to
cope with workplace stressors. Multimedia learning theory (MMLT) can be applied to make
recommendations. Mayer and Moreno (1998) suggested the learning process is maximized by
combining auditory and visual components, thus reinforcing procedural steps. Breaking down
learning concepts into smaller, more manageable parts reduces overload and increases working
memory. Subsequently, incorporating videos, diagrams, and other visual tools provides step-bystep procedures for learners to practice and receive feedback (Mayer & Moreno, 1998). This
suggests firefighters would benefit from training that demonstrates the systematic effect of stress
on the body over a period of time and a step-by-step approach to how to reduce the mitigate the
negative effects. It is recommended that the AFD provide stress management training with
practical applications (skills) where firefighters utilize different strategies and receive immediate
feedback.
The research literature implies that less than half of what is learned in training transfers
back to the job (Stolovitch, 1997). The greatest barrier to knowledge transfer is the failure to
provide useful learning during the training (Clark & Estes, 2008). To enhance knowledge
transfer, MMLT advocates integrating visual and verbal-based models so learners can build
connections between instructional information (Mayer & Moreno, 1998). A job aid such as a
resiliency toolkit can help firefighters learn and apply coping strategies for stress. Research has
found that resiliency toolkits are beneficial in providing firefighters with multiple techniques to
manage job-related stress.
Metacognitive Knowledge Solution
Provide coaching and feedback on self-regulation, self-awareness, and reflective
practices to reduce psychological stressors. Metacognitive knowledge refers to an individual’s

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understanding and awareness of their own cognitive processes and how they are interpreted by
others (Clark & Estes, 2008). The results and findings illustrated a need for metacognitive
knowledge that a mindfulness training workshop can improve firefighter psychological wellness.
Self-regulated learning theory can be applied to make recommendations. According to research,
learners play an active role in controlling, monitoring, and reflecting on their own learning
processes (Zimmerman, 1989). Self-reflection after stressful experiences encourages selfawareness and critical thinking. It enables individuals to guide their mental processes and
enhance decision-making (Zimmerman, 1989). This suggests that firefighters would benefit from
training workshops to improve psychological well-being. Thus, it is recommended to provide
coaching, feedback, and guidance on self-reflection skills to build mental resilience.
According to research, self-regulation is crucial for effective knowledge transfer and the
applicability of skills back to the job (Clark & Estes, 2008). Consequently, self-regulated
learning improves motivation and academic performance while helping individuals apply selfawareness skills (Zimmerman, 1989). Clark and Estes (2008) recommended introspection after
an activity to solidify existing knowledge and advance new insights, which facilitates adaptive
learning strategies. Learners can malleate their metacognitive processes by methodically
reflecting on their actions and outcomes, which increases tactics for learning. The
recommendation is to provide guidance, coaching, and feedback on self-flection skills to reduce
psychological stress.
Motivation Recommendations
An analysis of the data identified the assumed motivation influences and showed the
adaptive leadership, expectancy value, and utility value needs. Clark and Estes (2008) suggested
motivation is an intrinsic drive that initiates and sustains engagement through active choice,

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persistence, and mental effort. Motivation is essential for attaining performance and learning
objectives. Motivation is also used by leaders to enhance follower performance and continuous
engagement (Northouse, 2015). The stakeholder motivational influences address goal
achievement and align individual firefighter values with actions. Self-regulation suggests
individuals set personal standards based on their values, which motivate their behaviors and
actions (Bandura, 1991). Individuals prioritize their actions around endeavors that align with
their perceived value and are based on their ability (self-efficacy) to succeed (Clark & Estes,
2008). The following literature discusses the theoretical principles of assumed motivational
influences.
Adaptive Leadership Solution
Train firefighters within AFD to form peer support groups to share their experiences with
behavioral health challenges. Peer support groups humanize mental health and generate
momentum for increased command staff support.
The results and findings illustrated the need for adaptive leadership to mobilize
stakeholders to push for behavioral health resource allocation actively. The adaptive leadership
model can be applied to make recommendations. According to research, motivation is tied to
addressing adaptive challenges, those requiring individuals to alter their behaviors, values, and
processes (Heifetz & Linsky, 2009). Further research from Heifetz and Linsky (2009) explained
that motivation is influenced by aligning actions with values and balancing the disequilibrium
when individuals act outside their belief system. Leadership must create enough disequilibrium
to encourage change but not so much that it disengages people’s drive. Motivation grows when
individuals feel a sense of ownership during the change process, as it is tied to individuals’ sense
of identity. This suggests that firefighters would benefit from the belief that peer support groups

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would be vital for fostering collaborative problem-solving. Thus, peer support groups provide
value by increasing the collective support for mental health resources. Therefore, it is
recommended that AFD provide information about the value of peer support groups by aligning
new knowledge with department values.
Adaptive leadership encourages people to change by learning new behaviors and
attitudes, which allow them to grow and meet their challenges (Northouse, 2019). By creating
environments where individuals are encouraged to confront challenges, learning is accelerated
when individuals reflect on these experiences. According to Northouse (2015), adaptive
leadership has four constructs: systems perspective, biological perspective, service orientation
perspective, and psychotherapy perspective. The one construct that provides value to AFD is the
psychotherapy component, which emphasizes that successful adaptations exist when individuals
are in a supportive environment. The recommendation is to provide firefighters with information
about the value of peer support groups, which can motivate support for mental health resources
by aligning new knowledge with department values.
Expectancy Value Solution
I recommend providing firefighters with information about the value of mentorship
circles, which can offer guidance and shared experiences. The results and findings illustrated a
need related to expectancy value for a belief that mentorship circles can foster professional and
emotional growth. Expectancy value theory can be applied to make recommendations.
According to research, individuals who believe in their ability to succeed are more likely to
engage and persevere through challenges. Prior successful experiences positively influence the
expectation of success (De Simone, 2015). Learners are motivated when they receive support
from mentors and peers, which reflects their perceived importance of the task (intrinsic value).

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Further research from Eccles and Wigfield (2020) suggested that intrinsic value is not fixed and
can be established through mentors and peers by sharing experiences and creating autonomy for
learners. This suggests that firefighters would benefit from the belief that mentorship circles will
provide value. Thus, mentorship circles that offer firefighters guidance through shared
experiences can provide value for the learners. Therefore, it is recommended that AFD provide
information about the value of mentorship circles through discussion and modeling.
Utility Value Solution
I recommend providing firefighters with information on the importance of a behavioral
health program, which is critical for safety in high-stress environments. The results and findings
illustrated a need for utility value to believe a behavioral health program is vital for firefighter
operational readiness, career longevity, and overall well-being. Utility value theory can be
applied to make recommendations. According to research, utility value refers to how valuable a
task is perceived to achieve future goals (Eccles, 2006). Further research from Eccles (2006)
explains the correlation of knowledge to real-world scenarios, which increases learners’
motivation. The interview responses indicated a need for further exploration into a formal
behavioral health program. Program efficacy is justified by enhancing cognitive function and
decision-making, thus allowing firefighters to react quicker and make faster decisions under
pressure. Stress reduction training, peer support, and mentorship circles can reduce the risk of
emotional exhaustion that propagates physical decline, burnout, and early retirement. This
suggests that firefighters would benefit from the belief that a formal behavioral health program
will provide value. Thus, a behavioral health program that improves firefighter well-being can
provide value. Therefore, it is recommended that the department provide information about the
value of a formal behavioral health program through discussions and visual media tools.

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Organization Recommendations
Organizational influences are critical to achieving stakeholder goals. Analysis of the
interviews demonstrated deeply entrenched culture and practices within the fire service that
currently inhibit growth in the area of behavioral health education and wellness. Organizational
factors include structures, cultures, and processes that either support or hinder performance.
Barriers due to organizational factors can significantly impede effective performance, such as
inadequate resources, poor process design, or lack of support for desired behaviors.
Organizational Behavior Theory Solution
I recommend empowering HWC to implement behavioral health initiatives through
funding and leadership support. The results and findings illustrated a need in organizational
behavior to foster leadership support to advance a behavioral health program. Organizational
behavior theory can be applied to make recommendations. According to research, leaders need to
adapt and manage organizational culture to align with changing circumstances (Schein, 2017).
The above knowledge and motivational recommendations require both resources and authority to
achieve any level of success. Without either, HWC will be crippled in its attempts to enact
positive change in the department. Further research from Burke (2018) emphasizes leadership as
the key impetus of organizational transformation. Organizational behavior theory examines the
interplay among individuals, groups, and structures within an organization, as understanding that
interplay is essential to changing behavior (Schein, 2017). By ensuring HWC has sufficient
funding and authority to roll out its initiatives, AFD will send a strong message to its people and
the community at large that this program must succeed. This suggests firefighters would benefit
from the belief that command staff supports and funds behavioral health initiatives. Thus, a
behavioral health program can provide value to AFD personnel. Therefore, it is recommended

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that the organization support behavioral health initiatives and educate AFD personnel to
reinforce the commitment and value of the program.
Cultural Setting Solution
I recommend reducing the stigma of behavioral health disorders by implementing
screening and evaluations for all staff during annual physicals and improving departmental
culture and attitude toward mental health needs through educational workshops. The results and
findings in cultural setting influences illustrated a need to incorporate a behavioral health
component into the organization’s annual physical. Organizational theory can be applied to make
recommendations. These recommendations seek to address the cultural setting at AFD. A
cultural setting is a location where policies, practices, and groups of individuals come together to
accomplish an intersecting goal (Gallimore & Goldenberg, 2001). As discussed extensively in
Chapter Two, the fire service is an environment where individuals often suppress outward
displays of emotion (Thurnell-Read & Parker, 2008). Firefighters often fear repercussions such
as being ostracized by peers, shunned for future promotions, or gaining the stigma of being an
unfit firefighter by seeking help for behavioral health disorders (Thews et al., 2020).
By making a behavioral health assessment a routine part of the annual physical that all
firefighters undergo, individuals will not feel singled out for unique treatment within the
department being assessed. This helps improve their comfort level by discussing their mental
health status and possible needs. An annual behavioral health assessment has the added benefit
of early detection and intervention if individuals exhibit mental health needs. This can improve
the likelihood of successful treatment and long-term resiliency. Mandated annual interaction with
behavioral health care providers facilitates the building of trust so that even if an individual does

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not need services at that moment, he or she knows whom to reach out to if he or she does in the
future.
As discussed in the knowledge section of this chapter, implementing education and
awareness of behavioral health disorders can also contribute to culture change. Moreover, to
ensure success, leadership must assess the department’s implicit values and determine if they
align with the intended change initiatives (Clark & Estes, 2008). People sometimes fear what
they do not understand, so education can help firefighters gain understanding and a level of
comfort with discussing mental health disorders and how they pertain to the fire service in
particular. The knowledge can empower them to improve their attitudes toward previously
suppressed topics and improve departmental culture. This suggests firefighters would benefit
from annual behavioral health assessments. Thus, adding a behavioral health component to the
annual physical can benefit firefighters. Therefore, it is recommended that the organization
mandates a behavioral health component within annual physicals.
Integrated Implementation and Evaluation Plan
The primary objective of these recommendations is to address the needs identified in the
gap analysis in the areas of KMO at AFD. Addressing the needs is essential to achieving the
stakeholder goal of conceptualizing and implementing a behavioral health program. The design
of the program is informed by the KMO recommendations derived from in-depth interviews with
current AFD personnel. Together, these program and stakeholder goals align with addressing the
current and future mental health crises facing the fire department as an industry.
Implementation and Evaluation Framework
I utilized the new world Kirkpatrick model to generate the implementation and evaluation
framework (Kirkpatrick & Kirkpatrick, 2016). The original model was developed in the 1950s

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by Dr. Don Kirkpatrick in his dissertation at the University of Wisconsin, where his area of focus
was teaching management and supervisory programs in businesses. The model identifies four
levels (Table 13), which form the basis of this fundamental training evaluation model.
Table 13
The Four Levels
Level Description
Level 1: Reaction The degree to which participants find the training favorable, engaging,
and relevant to their jobs
Level 2: Learning The degree to which participants acquire the intended knowledge, skills,
attitude, confidence, and commitment based on their participation in the
training
Level 3: Behavior The degree to which participants apply what they learned during training
when they are back on the job
Level 4: Results The degree to which targeted outcomes occur as a result of the training
and the support and accountability package
Note. From Kirkpatrick’s Four Levels of Training Evaluation (1st ed.), by J. D. Kirkpatrick &
W. K. Kirkpatrick, 2016. Association for Talent Development. Copyright 2016 by James D.
Kirkpatrick and Wendy Kayser Kirkpatrick.

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In the original model, Level 1 represented the reaction to the degree to which participants
found the training favorable, engaging, and relevant to their jobs. Level 2 represented learning,
the degree to which participants acquire the intended knowledge, skills, attitude, confidence, and
commitment based on their participation in the training. Level 3 represented behavior, which is
the degree to which participants apply what they learned during training when they are back on
the job. Lastly, Level 4 represented the final results, which were the degree to which the targeted
outcomes occurred as a result of the training and the support and accountability package.
The new world Kirkpatrick model, however, builds on the original and was developed by
Dr. Kirkpatrick’s son and daughter-in-law. The new world model maintains the four levels
(albeit in reverse) while adding new elements to help new users operationalize them effectively
in a wide array of industries (Figure 9). The new model recommends the reverse order during the
planning phase of a program. This keeps the focus on the overall outcome, the desired effect that
can be accomplished through improved on-the-job performance of those receiving the training. It
also asks the user to identify which behaviors (Level 3) will lead to the desired outcome.
Working backward again, the user must then identify what training (Level 2) would lead to the
desired behaviors. Lastly, considering the reaction (Level 1) to such training being delivered is
essential to gauge how it will be received by the participants.

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Figure 9
The New World Kirkpatrick Model
Note. From Kirkpatrick’s Four Levels of Training Evaluation (1st ed.), by J. D. Kirkpatrick &
W. K. Kirkpatrick, 2016. Association for Talent Development. Copyright 2016 by James D.
Kirkpatrick and Wendy Kayser Kirkpatrick.
Level 4: Results and Leading Indicators
Results are the degree to which targeted outcomes occur as a result of the training and the
support and accountability package (Kirkpatrick & Kirkpatrick, 2016). These are broad,
company-wide goals, as opposed to the goals of small, individual areas of an organization. Table
14 lists the outcomes, metrics, and methods for both external and internal outcomes. External
outcomes apply to those that originate from outside of HWC. Internal outcomes, on the other
hand, refer to those that originate from within HWC. The desired external outcome for the
program is a statistically significant decrease in firefighter-reported suicide, PTSD, compassion

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fatigue, burnout, and substance abuse. The desired internal outcome for the program is a
significant decrease in the mental health burden in AFD, as indicated by a reduction in mental
health sick days.
Table 14
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External outcomes
Decrease in reported
firefighter suicide, PTSD,
compassion fatigue,
burnout, and substance
abuse
Statistics published by
industry organizations
Track the frequency of
mental health related issues
in industry reports
Increased public approval of
HWC behavioral health
initiatives
Dedicated behavioral health
section in monthly
community newsletter
Monitor frequency of
community feedback in
response to behavioral
health content
Increased behavioral health
education in the fire service
at state and national levels
List of behavioral health
courses offered by AZ Fire
Training Committee
Monitor curriculum of the AZ
Fire Training Committee
Internal outcomes
Improved mental health of
AFD employees
Number of mental health sick
days
Track number of mental
health sick days
Improved organizational
culture regarding mental
health issues (reduced
stigma)
Employee engagement
surveys
Compare survey results
quarterly
Increased behavioral wellness
education at AFD
Number of AFD-taught
behavioral health
workshops
Track number of behavioral
health workshops

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Due to the broadness of most organizational results, more tangible indicators of progress
are needed. Leading indicators assist in bridging the gap between organizational results and
individual initiatives. They are short-term observations and measurements that are suggestive of
a positive impact on critical behaviors on the overall result (Kirkpatrick & Kirkpatrick, 2016).
Level 3: Behavior
Level 3 encompasses behavior, which is the degree to which participants apply what they
learned during training when they are back on the job (Kirkpatrick & Kirkpatrick, 2016).
Critical Behaviors
Specifically, critical behaviors are those that have been identified as the most important
to achieving the determined outcomes. Table 15 describes three critical behaviors for the
proposed HWC’s behavioral health initiative. The first is the incorporation of mental health
assessments into the annual physicals that AFD’s firefighters must undergo. HWC will monitor
this based on data provided by the CMP, who is one of the stakeholders in this initiative. The
second critical behavior is awareness training at multiple levels. Anytown Fire Department itself
can organize behavioral health workshops to be taught as a part of on-the-job training. This will
be monitored by tracking the number of workshops given annually and will elicit feedback in the
form of satisfaction surveys. The last critical behavior is to include a behavioral health
curriculum during fire academy training. This has enormous potential for impacting firefighters
because it can assist in mitigating moral injury early in their careers. These courses will need to
be taught by mental health professionals with experience treating first responders to get adequate
buy-in from their audience. These curricula will be monitored quarterly for number and quality
as indicated by student feedback.

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Table 15
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical behavior Metrics Methods Timing
1. Annual physicals,
including mental
health assessment
Percentage of AFD
employees receiving
mental health
assessments
Data provided by
partnered CMP
Annual
2. Awareness training Number of behavioral
health workshops
taught at AFD
Track number of
workshops and analyze
satisfaction surveys
Monthly
3.Behavioral health
included in firefighter
academy curriculum
Quality and number of
courses taught by
mental health
professionals
Monitor fire academy
curriculum, student
feedback surveys
Quarterly
Note. Items are numbered for easier identification in Table 16.
Required Drivers
These critical behaviors are often difficult to achieve and require additional infrastructure
to improve the likelihood of success. Required drivers are processes and systems that reinforce,
monitor, encourage, and reward the performance of critical behaviors on the job (Kirkpatrick &
Kirkpatrick, 2016). These could include a wide range of tools such as job aids, coaching,
monetary incentives, and recognition for a job well done. They are the key to supporting the
critical behaviors needed to achieve organizational success. Table 16 lists the required drivers for
the three critical behaviors identified.

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Table 16
Required Drivers to Support Critical Behaviors
Methods Timing
Critical
behaviors
supported
Reinforcing
Mental health assessment is a mandatory component of
physicals
Annual 1
Provide behavioral health awareness training that models
industry standards.
Ongoing 2, 3
Create peer support groups within the fire academy Ongoing 2, 3
Encouraging
Online meeting designed to ensure awareness training
meet industry standards. Also allows firefighters to
share experiences of the current program
Monthly 2, 3
Community newsletter featuring behavioral health topics Monthly 2, 3
Communication from command staff to AFD personnel
about importance of behavioral health initiatives
Quarterly 1, 2, 3
Rewarding
Certificates of completion for completing workshops and
courses
Ongoing 2, 3
Public acknowledgement during team meetings, email,
and monthly newsletter
Ongoing 1, 2, 3
Challenge coins for completing the training Ongoing 1, 2, 3
Monitoring
Monthly meetings with HWC Ongoing 1, 2, 3
Action planning by command staff to ensure quality
assurance of the program
Ongoing 1, 2, 3
Fire chief creates policy to foster an organizational
culture that prioritizes behavioral health.
Ongoing 1, 2, 3
Organizational Support
Implementing these changes will require a significant amount of organizational support at
multiple levels. The Office of the Fire Chief and Command Staff will perform critical behaviors
to enact climate change and support a positive shift in culture toward behavioral health education
and treatment. Fostering trust between leadership and line personnel to address these critical

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issues is essential for long-term success. Lastly, the organization as a whole will need to provide
both leadership and line personnel with the tools they need to maintain a healthier mindset in the
fire service.
Level 2: Learning
According to the new world Kirkpatrick model, learning represents the degree to which
participants acquire the intended knowledge, skills, attitude, confidence, and commitment based
on their participation in the training (Kirkpatrick & Kirkpatrick, 2016). There are five
components of learning as well: knowledge, skills, attitude, confidence, and commitment. There
are multiple ways to evaluate and support the learning process.
Learning Goals
Based on the recommendations discussed earlier in this chapter, multiple learning goals
have been developed for those participating in the behavioral health initiative through HWC.
One year following the implementation of the initiative, the participants and stakeholders will be
able to
1. Understand the most common behavioral health disorders affecting members of the
fire service as well as the prevalence of problems compared to other professions.
2. Understand the factors intrinsic to the fire service that contribute to the development
of such disorders.
3. Identify the ways in which stigma and culture in the fire service have affected the
way in which mental health crises were previously managed.
4. Understand the mission of the behavioral health initiative and the individual
components of the program.

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5. Understand the reasoning and results of their personal mental health evaluation that is
administered with the annual physical, as well as the importance of any recommended
follow-up.
6. Identify what resources are available through HWC as well as those offered by local,
state, national, and international organizations to assist with education and support of
mental health.
7. Identify both healthy and unhealthy coping mechanisms for stress.
8. Participate in a roleplay interaction involving the identification of a colleague
exhibiting signs of mental health stress, demonstrate empathetic listening, and guide
the colleague to appropriate resources.
9. Design and execute individual action plans to safeguard their own mental health and
that of their peers.
10. Identify and utilize the mechanisms by which to give feedback about the various
components of the behavioral health initiative.
Program
The goal of this program is to develop a multifaceted behavioral health initiative that will
address the needs identified in the KMO analysis in Chapter Four. This initiative will seek to
support stakeholder learning goals through a year-long educational experience delivered in
multiple settings. The three primary components of the behavioral health initiative are
• adding a behavioral health component to the annual physicals
• partnering with a CMP who specializes in evaluating and treating first responders
• implementing departmental workshops to educate about behavioral health challenges
in the fire service

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The first component of this initiative involves adding a behavioral health assessment to
the annual physicals that all firefighters must undergo at AFD. The impact of this intervention is
two-fold. The first effect will be to normalize receiving an assessment of this kind. If all
firefighters must undergo the assessment, individuals do not feel ashamed or singled out for a
potential weakness. Secondly, this allows for early detection of behavioral health disorders such
as PTSD, depression, or suicidality. Early detection can lead to early intervention and potentially
save lives.
The second component includes building a relationship with a CMP to provide mental
health care for those who need it in AFD. This individual would have either specialized training
or significant experience treating first responders and have a strong understanding of the
workplace stressors that firefighters face. In addition, this medical provider will be involved with
multiple behavioral health workshops in which the firefighters participate. This allows the CMP
to build rapport with firefighters in a less threatening setting in which numerous staff are
interacting with him or her at once. Once trust and rapport have been established, it will likely be
easier for firefighters to seek mental health services as they have some idea of what to expect.
As alluded to above, the third component of the intervention involves establishing
monthly workshops to educate firefighters regarding behavioral health issues. This would help
increase awareness of multiple conditions as well as types of treatment. These workshops would
be taught by several individuals to gain a wide perspective on various topics. Workshop leaders
would include the CMP, HWC staff, or guest speakers from local or other fire associations. The
workshops would contain an interactive component so that firefighters could begin to feel
comfortable discussing these issues openly.

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Evaluation of the Components of Learning
The behavioral health initiative, particularly the educational workshops, seeks to
broaden firefighters’ understanding of mental health challenges in the fire service. Each of the
five components of learning (knowledge, skills, attitude, confidence, and commitment) is critical
to enacting lasting change among employees. Table 17 identifies the methods or activities that
will be utilized to evaluate the five components of learning, as well as the timing of the
evaluation.
Table 17
Evaluation of the Components of Learning for the Program
Methods or activities Timing
Declarative knowledge: “I know it.”
Knowledge checks using focus groups and surveys During in-person training
Knowledge checks through discussions During in-person training
Brief pulse check during courses During in-person training
Procedural skills: “I can do it right now.”
Role-playing identifying effects of mental health on
colleagues
During in-person training
During training, participants demonstrate the positive
coping mechanisms of handling stress from routine job
duties.
During in-person training
Brief pulse check during courses During in-person training
Attitude: “I believe this is worthwhile.”
During training, have participants explain why the topics
are important.
During in-person training
Discuss the value of the mission. During in-person training
Brief pulse check during courses During in-person training
Confidence: “I think I can do it on the job.”
Self-efficacy survey Following in-person training
Discussion groups following the in-person training Following in-person training
Commitment: “I will do it on the job.”
Identify individual and organizational goals. Following in-person training
Develop individual action plan. Following in-person training
Self-reported progress Following in-person training

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Level 1: Reaction
According to the new world Kirkpatrick model, reaction is the degree to which
participants find the training favorable, engaging, and relevant to their jobs (Kirkpatrick &
Kirkpatrick, 2016). This level provides methods and tools to measure the reactions to the
program as it is being established, including participant engagement, perceived relevance, and
customer satisfaction. As discussed in Chapter Two, adaptive change often involves loss and
discomfort. This impacts the change initiative’s motivation (Heifetz et al., 2002). Measuring
reactions and managing any distress caused by the change is necessary so that participants can
function and learn. Table 18 lists these methods and tools, as well as the timing of evaluation.
Table 18
Components to Measure Reactions to the Program
Methods or tools Timing
Engagement
Completion of behavioral health courses and
workshops
During in-person training
Attendance rate Beginning and end of training
Pulse checks In between modules of in-person training
Relevance
Group and individual reflection During in-person training
Course evaluation survey Following in-person training
Pulse checks During in-person training
Customer satisfaction
Group discussions during each course During in-person training
Course evaluation survey Following in-person training
Pulse checks Following in-person training

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Evaluation Tools
In order to deliver the most effective program possible, meaningful evaluation of its
progress and lasting effects is imperative. Integrating the evaluation method with program design
can confer the greatest impact. Kirkpatrick and Kirkpatrick (2016) advocated for the “Blended
Evaluation®,” an evaluation methodology in which data are collected from multiple sources
using multiple methods, in a fashion that considers all four Kirkpatrick models.
Immediately Following Program Implementation. Throughout the 1st year of
implementation, attendance at the workshops will be tracked. Frequent pulse checks during
workshops will solicit ongoing feedback about areas such as the applicability of the material
presented, organization, and overall learning environment. Evaluation will be integrated into the
entire learning and development process for maximum effectiveness, not just as an afterthought.
Pertinent comments will be noted and compiled by the instructors for analysis. Participants will
be given brief, open-ended surveys after each workshop regarding the material’s utility and
presentation (Appendix D). Following the completion of the 1st year, a more in-depth Likertstyle survey will be given to the participants, soliciting their opinion of the material presented
and the program overall. In addition, open-ended questions and opportunities for constructive
criticism and recommendations will be provided. See Appendix E for a sample post-program
survey.
Delayed After Program Implementation. Ninety days following the completion of the
program, a follow-up evaluation will be sent out via email to those who participated (see
Appendix F). This evaluation will also include Likert-type questions and several open-ended
queries. This allows the organization to evaluate the effectiveness of the curriculum. In the new
world Kirkpatrick model (Kirkpatrick & Kirkpatrick, 2016) context, the effectiveness of all four

127
levels will be examined (Table 13). The survey items will measure if the information and skills
learned during the workshops apply to their mental health journey. Further recommendations for
changes to the program will also be solicited.
Data Analysis and Reporting
An analysis of the findings will be shared with program participants and used to generate
momentum for the behavioral health program. Findings will include themes arising from the
evaluations and how KMO influences affect program efficacy. Communicating the quality of the
data ensures that the results are trustworthy (Merriam & Tisdell, 2016). Trust fosters
collaboration and generates buy-in to the program. Communicating the results to the HWC will
accelerate their understanding of the data and allow them to transfer the knowledge to the rest of
the department. Program participants will be asked to provide testimonials to determine if the
program design meets the organization’s needs. Identified needs will inform decision-making,
assisting the HWC in improving the behavioral health program. As internal stakeholders,
participant feedback will identify patterns and gaps in program performance, leading to
actionable interventions. Testimonials immediately and 90 days after program completion will be
compared to see if the program has the desired effects on firefighter performance. The HWC can
observe positive change by reducing mental health day callouts over the 90-day period following
program completion. The comparative examination is used as a post-training tool, which
provides proactive data analysis that will be used to maximize the behavioral health program
outcomes (Kirkpatrick & Kirkpatrick, 2016).
Limitations and Delimitations
Methodological choices influence the limitations and delimitations of qualitative research
(Merriam & Tisdell, 2016). This study aimed to assess the KMO influences on behavioral health

128
program design, implementation, and evaluation within the AFD. As with most qualitative
studies, there were multiple limitations. The data’s significance depended on the interviewee’s
willingness to be detailed and transparent about their insights. Due to the political nature of the
work environment, two participants who initially agreed to be interviewed later withdrew their
consent. It is not known how many interviewees withheld information or malleated their
responses to be neutral and not draw attention to negative responses. Subsequently, the
interviewee pool was comprised of a minor, non-random sample. This results in context-specific
information regarding AFD that is not generalized to larger populations or even regional fire
departments. The interview protocol stated that the interviews would be between 45 and 60
minutes. However, interviewee schedules limited the time-intensiveness to expand and elaborate
on details, reducing the richness of the responses. Additionally, the subjectivity of the interview
data is shaped by researcher biases, interpretations, and perspectives, thus providing another
limitation. Researcher bias can stem from the researcher’s close involvement with data collection
and the relationship with the interviewees. Even though I did not supervise the interviewees, they
are employed by the same organization, which could have influenced the interpretation of
information, as stated above.
Conversely, this study contained several delimitations. Delimitations reference a study’s
boundaries. The theoretical lens the researcher used to interpret the data bounded this study. The
KMO framework may not be familiar to AFD personnel, resulting in an incomplete
understanding of the data and how the influences contribute to behavioral health program design
and implementation. The scope of the study was comprised of a particular fire department,
geographical location, and challenges, which the research questions represented. The study also
took place within a particular time frame and extracted data from interviewees with different

129
amounts of time on the job. These temporal boundaries limit the applicability of data to those
outside the time frame. The study interviewed members of the organization’s HWC, who
maintained behavioral health program design authority. This participant selection set the
inclusion boundary for the study, thus influencing the findings (Merriam & Tisdell, 2016). I
identify as a member of the AFD with many years of experience. This has allowed him to build
rapport with firefighters of varying age groups and various lengths of experience. This assisted in
his ability to design relevant interview questions that facilitated the eliciting of KMO influences.
Recommendations for Future Research
Behavioral and mental health efforts are accelerating in the fire service. Behavioral and
mental health is attracting media attention, and departments have suffered the long-lasting effects
of not prioritizing programs that mitigate the challenges that come with routine job duties. This
research was designed to illustrate the barriers existing in behavioral and mental health program
development and implementation. Three areas of significance materialized through literary
review and interview data for future research to build upon this study.
Initially, research should be conducted to determine if the routine job responsibilities of
firefighters are the cause of behavioral and mental health conditions or if the role exacerbates
preexisting conditions. Alternatively, are outside lifestyle factors at play and how so? It would be
instrumental in pinpointing what specific facets of the job correlate to specific behavioral health
conditions. For example, what scenes/environments cause an increase in suicidality or PTSD
compared to compassion fatigue? Knowing this information could contribute to a crucial
understanding of the design of mitigation strategies for adverse reactions to harsh incidents.
Subsequently, what if the most significant contributor is sleep deprivation and not gruesome
incidents? That would spur a conversation about changing shift schedules and prioritizing sleep

130
patterns, which would be an adaptive challenge for the fire service because resistance would be
substantial.
Furthermore, since rates of suicide have risen consistently for the past 12 years, should
the fire service conduct pre-hire behavioral health evaluations to determine if a person is more
susceptible and less resilient to death and injury? Mental and behavioral health conditions cost
money to mitigate and treat. If insurance companies raise premiums on fire personnel due to the
prevalence of mental health (the data says it is an increasing problem), research would aid in
supporting or opposing such future measures.
Secondly, research on peer support teams should be applied to evaluate their
effectiveness on fire personnel. Peer support groups are made up of trained firefighters, retired
fire personnel, or a combination of the two that provide support for firefighters experiencing
emotional, personal, or work-related stress. Fire departments began incorporating these teams
over a decade ago, yet rates of PTSD, suicide, compassion fatigue, burnout, and sleep
deprivation have continued to rise. Peer support teams are not legally confidential and may be a
barrier for fire personnel to use their services. Research on what departments are receiving the
desired outcomes from their peer support teams could provide insight into what is working and
what is failing for other departments.
Supplementary research would be beneficial once the AFD establishes a behavioral and
mental health program. The data from interviewees revealed a general lack of behavioral health
knowledge, which factors into their ability to recognize and help others experiencing similar
dispositions. The AFD does not have a clinical practitioner on staff, which may be needed for
future confidentiality and assessment of department personnel. It would be valuable to see

131
whether a contracted clinician increases the motivation of AFD personnel to reach out for
assistance and what kind of effect this has on sick leave callouts and overall department morale.
Lastly, continuing research should be piloted to assess what behavioral and mental health
education is being delivered nationally and in the state. Because a fire department offers
behavioral health services, personnel still need to receive the necessary resources. What
certifications and qualifications are held by individuals delivering these services? Should fire
departments sponsor their personnel through professional counseling or psychology programs?
Not long ago, firefighter I and II certifications were required to apply for a firefighter position,
and then EMT certification was required. Should departments require additional certifications in
sociology/psychology for new applicants? Moreover, what does this look like? Research would
be valuable to the stakeholders of the fire service to know exactly what changes are needed to
ensure the best delivery of internal and external services relating to behavioral and mental health.
Conclusion
This research specified the organizational, motivational, and knowledge influences that
have limited the development and implementation of a formal behavioral health program within
the AFD. Ongoing mental health education is essential to AFD because rates of suicidality,
PTSD, compassion fatigue, burnout, and sleep deprivation are affecting firefighters at a greater
rate than the general population. Knowing this, AFD must establish a formal behavioral and
mental health program. Waiting for state agencies to build a program AFD can copy is not a
healthy choice because education is needed now. The research intends to assist AFD in building
its behavioral health program by identifying barriers that need alleviation. This program could be
built and delivered to our regional partners if our program’s objectives meet the desired
outcomes.

132
The literature review on behavioral and mental health issues in the fire service identified
numerous influences that support the need for more knowledge about AFD. These issues
comprised significant trends of what behavioral health aspects encompass fire personnel, what
resources are available for firefighters seeking assistance, historical and current statistics, and
what local, regional, and national agencies are doing to address these issues. Suicide, burnout,
compassion fatigue, and PTSD are significant challenges within the fire service and affect fire
personnel more than the general population. While research has indicated that occupational
stressors of routine firefighter duties influence these conditions, it is not yet known how much
personal control firefighters have over them. Since AFD does not educate firefighters on stress
coping mechanisms, it cannot be ascertained that all behavioral health conditions are out of our
control.
The literature review recognized national standards, such as NFPA 1500, as a foundation
for behavioral health and wellness program development. National and non-profit organizations
such as the IAFC, NVFC, IAFF, NFFF, FBHA, and NFPA have concocted initial guidelines to
orchestrate proactive measures for identifying and shaping mental health programs. However, no
national or state curricula on firefighter behavioral health programs were identified. Research has
increased in this paradigm, and the future is promising. The AZCFSE training calendar and the
National Fire Academy courses were evaluated during the literature review. Neither entity
offered more than an introductory awareness course on mental health. This demonstrates the
need for institutions to take the lead and create urgency in this field, as they have the platform to
influence the fire service substantially. Furthermore, fire departments look to their training
agencies on all levels for examples, and there currently needs to be more program development
and implementation. This research was specific to AFD. However, if occupational stressors

133
affect the fire service to such a degree, the entire industry should be adequately trained to reduce
the effects of these conditions. If we cannot take care of each other, what message does that send
to our external stakeholders that we can take care of them?
The AFD acknowledged a desire for efficient behavioral and mental health knowledge
and education to produce an effective program. The research illustrated that AFD needed the
KMO resources to produce such a program and what is needed for implementation. From the
research, it is apparent that behavioral and mental health issues are continuing to rise in the fire
service, and current solutions have not reversed this trend. Disseminating knowledge about
mental health, from the academy to retirement, may be a profound first step. There are also stress
mitigation tactics that should be incorporated into department training, which may alleviate
many of the underlying symptoms provoking suicidality, PTSD, compassion fatigue, burnout,
and others. Local, state, and national efforts will be needed to establish a robust program that
produces a cultural change within the fire industry. This research should continue the
conversation about behavioral and mental health and motivate all levels of the AFD to prioritize
these goals.

134
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Appendix A: High Burnout
Table A1 presents data on high burnout associated with any sleep disorder, any mental
health condition, and any sleep disorder by any mental health condition interaction term.
Table A1
High Burnout Outcomes
Burnout
outcomea
, n
b
Included
variables B (SE) OR 95% CI p-value
EE
Constant –2.729
(0.069)
Any sleep
disorderc 1.106 (0.091) 3.022 2.528–3.613 < 0.0001
Any mental
health
conditionc
1.158 (0.206) 3.183 2.125–4.767 < 0.0001
Any sleep
disorderc by
any mental
health
conditionc
–0.193
(0.243) 0.825 0.512–1.328 0.428
DP
Constant –1.911
(0.049)
Any sleep
disorderc 0.700 (0.072) 2.013 1.747–2.320 < 0.0001
Any mental
health
conditionc
0.662 (0.184) 1.938 1.352–2.779 < 0.0001
Any sleep
disorderc by
any mental
health
condition
c
0.012 (0.222) 1.012 0.655–1.564 0.958
PA
Constant –0.624
(0.035)
Any sleep
disorderc 0.300 (0.057) 1.350 1.208–1.509 < 0.0001
Any mental
health
condition
c
0.173 (0.155) 1.189 0.878–1.610 0.264

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Burnout
outcomea
, n
b
Included
variables B (SE) OR 95% CI p-value
Any sleep
disorderc by
any mental
Health
Conditionc
0.145 (0.194) 1.156 0.790–1.691 0.457
High degree
Constant –3.952
(0.122)
Any Sleep
Disorder 1.133 (0.155) 3.104 2.289–4.210 < 0.0001
Any mental
health
conditionc
0.985 (0.363) 2.677 1.315–5.451 0.007
Any sleep
disorderc by
any mental
health
conditionc
0.171 (0.404) 1.187 0.538–2.618 0.671
Note. EE, emotional exhaustion; DP, depersonalization; PA, personal accomplishment; OR, odds
ratio; CI, confidence interval
aHigh versus low to moderate score on burnout dimension. Hhigh EE, high DP, with low PA.
cMissing or not known outcomes not included.

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Appendix B: Informed Consent for Research
University of Southern California
USC Rossier School of Education
3470 Trousdale Parkway
Los Angeles, CA 90089
INFORMED CONSENT FOR RESEARCH
Study Title: Gaps in Organizational Mental Health Mitigation in the United States Fire Service
Principal Investigator: Dustin L. Zamboni
Faculty Advisor: Patricia Tobey, PhD
Department: Rossier School of Education
24-Hour Telephone Number: 1-800-273-8255
INTRODUCTION
You are invited to participate in a research study. Please take as much time as necessary to
review the consent form thoroughly. You can discuss its contents with your family, friends, or
physician. If you need more explicit language, feel free to ask questions for clarification. If you
choose to participate, you must sign this form.
DETAILED INFORMATION
PURPOSE
This study aims to perform a gap analysis to identify the variables that hinder the Anytown Fire
Department’s development of a formal behavioral health program within its health and wellness
framework. This research is being conducted to fulfill the requirements for the researcher’s
doctoral dissertation at the University of Southern California. The knowledge gained from your
experiences will contribute to the existing literature on the relationship between fire personnel
and behavioral health programs. The aim is to identify and mitigate the obstacles that inhibit the
growth of this program, thereby facilitating its progression. You have been invited to participate
due to your experiences with the Anytown Fire Department and its associated behavioral health
programs. Approximately 10 participants will take part in the study.
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PROCEDURES
If you decide to take part in this study, you will be required to fill out a consent form. All
participants are required to conduct a 60-minute recorded audio/video interview on the cloud-

155
based video conferencing platform Zoom. However, you can choose to conduct the interview
without video and audio-only recording. All transcripts from the interview will be downloaded
for analysis and deleted at the end of the study.
The interview will collect data through your lived experience seeking and receiving behavioral
health services. To protect confidentiality, no fire department title, command name, position, or
rank will be identified during the interview. The researcher will ask you 19 open-ended
questions, which you can skip or stop answering if they make you feel uncomfortable.
RISKS AND DISCOMFORTS
Risks and discomforts you could experience during this study include nervousness, emotional
discomfort, triggers from memories, or painful bereavement.
Interviews: Some of the questions may make you feel uneasy or uncomfortable. You can choose
to skip or stop answering any questions you don’t want to.
Breach of Confidentiality: There is a small risk that people who are not connected with this
study will learn your identity or your personal information. All information shared with the
researcher will be private and stored in a safe location and used only for this research purpose.
BENEFITS
There are no direct benefits to you from taking part in this study. However, your participation in
this study may help us learn more on the complexities of Anytown Fire Department’s behavior
health service experiences. Contribution to literature on this topic may lead to improved and
effective behavioral health resources for Anytown Fire Department.
PRIVACY/CONFIDENTIALITY
We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you. Efforts will be
made to limit the use and disclosure of your personal information, including research study and
medical records, to people who are required to review this information. We may publish the
information from this study in journals or present it at meetings. If we do, we will not use your
name.
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The University of Southern California’s Institutional Review Board (IRB) and Human Subjects
Protections Program (HSPP) may review your records.

156
Your data collected as part of this research will be used or distributed for future research studies
without your additional informed consent. Any information that identifies you (such as your
name) will be removed from the data before being shared with others or used in future research
studies.
To understand the privacy and confidentiality limitations associated with using Zoom, we
strongly advise you to familiarize yourself with their privacy policies at
https://explore.zoom.us/en/privacy/.
ALTERNATIVES
An alternative would be to not participate in this study.
PAYMENTS / COMPENSATION
You will not be compensated for your participation in this research. However, your participation
will help increase awareness through challenges faced by Anytown Fire Department.
VOLUNTARY PARTICIPATION
It is your choice whether to participate. If you choose to participate, you may change your mind
and leave the study at any time. If you decide not to participate, or choose to end your
participation in this study, you will not be penalized or lose any benefits to which you are
otherwise entitled.
PARTICIPANT TERMINATION
You may be removed from this study without your consent for any of the following reasons: you
do not follow the study researcher’s instructions, at the discretion of the researcher, or if you do
not sign the consent form.
CONTACT INFORMATION
If you have questions, concerns, complaints, or think the research has hurt you, talk to the
study researcher Dustin Zamboni at zamboni@usc.edu (or 602 399 5678) or the faculty
advisor, Patricia Tobey, PhD, at tobey@usc.edu (or 213 740 0776).
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This research has been reviewed by the USC Institutional Review Board (IRB). The IRB is a
research review board that reviews and monitors research studies to protect the rights and
welfare of research participants. Contact the IRB if you have questions about your rights as a

157
research participant or have complaints about the research. You may contact the IRB at (323)
442-0114 or by email at irb@usc.edu.
STATEMENT OF CONSENT
I have read the information provided above. I have been given a chance to ask questions. All my
questions have been answered. By signing this form, I am agreeing to take part in this study.
Name of Research Participant Signature Date Signed
Person Obtaining Consent
I have personally explained the research to the participant using non-technical language. I have
answered all the participant’s questions. The participant understands the information described in
this informed consent and freely consents to participate.

Name of Person Obtaining Signature Date Signed
Informed Consent
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Appendix C: Interview Protocol
Thank you again for taking the time to be a part of the interview today. As a reminder, I
am a doctoral student gathering data for my dissertation. I am interested in understanding the
impact of behavioral health programs on an individual’s well-being within an organization.
Introduction
May I have your permission to go ahead with questions over the next 45 minutes? I
would also like your permission to record this interview for my future reference; the recording is
not available for others. Your responses will be confidential, and the results get aggregated into a
collective data set without individual identifiers. Thank you again for your participation; let us
get started. Three research question guide this study:
1. How do HWC describe the needs of a behavioral health program with AFD?
2. What are the key organizational barriers to the implementation of a behavioral health
program?
3. What strategies can be used to address the assessed needs of AFD concerning mental
health mitigation?
I would like to start by asking you some questions about your position within your
organization and how it correlates with behavioral health programs.
• Do you work for a career fire department (demographic/factual knowledge)?
• How long have you worked in the fire service (demographic/factual knowledge)?
• Does your department have a behavioral health program (conceptual knowledge)?
• What do you think should be included in a fire department behavior health program
(conceptual knowledge)?

159
• How many critical stress events have you experienced at work (conceptual
knowledge)?
• Do you feel your stress as a firefighter has caused unresolved
psychological/emotional issues (metacognitive knowledge)?
• How satisfied are you with your department’s managing of stress management
(procedural knowledge and organization)?
• Do you feel fire department cultural stigma forms a barrier to seeking help for
behavioral issues (factual and conceptual knowledge and organization)?
• How important is a new health program to you? What value do you see? Motivation
• How often have you used your employer’s employee assistance program (EAP) for
job stressors (motivation and organization)?
• Describe your department’s critical incident stress debriefing (procedural knowledge
and organization).
• Outside of the EAP, are there any behavioral health services available to you (factual
knowledge and organization)?
• Have you ever sought help from a fellow firefighter (motivation and organization)?
• If yes, did you find that peer support beneficial (metacognitive knowledge)?
• What organizational barriers do you perceive (organization)?
• Do you believe there is sufficient behavioral health services for fire personnel
(organization)?
• Do you believe increased behavioral health awareness in the fire service will lead to
more resources being distributed to address these issues (motivation and
organization)?

160
• Do you feel your department distributes sufficient behavioral health resources
(factual/metacognitive knowledge, motivation, and organization)?
• How often does your department supply behavioral health awareness training (factual
knowledge and organization)?
Conclusion to the Interview: Post-interview Comments
Name of person, thank you for taking time to meet with me and invest in this research.
As a senior member of a fire department this research will be used to formulate behavior health
programs and positively influence the outcomes of occupational stressors in the workplace.
Thanks again for sharing your thoughts, and I will present the results to you when the
study is completed.

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Appendix D: Post-workshop Survey
Workshop Topic: ____________________________
Workshop Date: _____________________________
Workshop Instructor: _________________________
Strengths of workshop:
Areas for improvement:
Comments for instructor:

162
Appendix E: Post-program Evaluation Tool
Instructions: For the following statements, please rate your level of agreement with each
of the following statements.
Table E1
Post-program Evaluation Tool
Statement Strongly
disagree Disagree Neutral Agree Strongly
agree
I found the workshops relevant to daily life.     
The workshops were well-organized.     
The workshops were easy to understand.     
I understand the purpose of the workshops.     
I know how a career in the fire service
increases the risk for behavioral health
problems.
    
I know the three most common mental health
disorders among fire personnel.     
I found the workshop discussions engaging.     
I found the roleplay scenarios valuable.     
I know what mental health resources are
available to me at AFD and beyond.     
I feel comfortable reaching out for mental
health assistance if I need it.     
I foresee being able to apply this knowledge
in my daily life.     
I would recommend this training to other fire
personnel.     
Most relevant and engaging workshop:
Least relevant and engaging workshop:

163
Statement Strongly
disagree Disagree Neutral Agree Strongly
agree
Recommendations for program
improvement:
Additional comments:

164
Appendix F: Delayed Evaluation Tool
Instructions: For the following statements, please rate your level of agreement with each
of the following statements.
Table F1
Delayed Evaluation Tool
Statement Strongly
disagree Disagree Neutral Agree Strongly
agree
I gained relevant knowledge from the program
regarding behavioral health.     
I found the program to be engaging.     
I can apply what I learned from the program to
daily life.     
I feel confident in the knowledge I gained from
this program.
    
I can apply the skills I learned in daily life.     
I feel comfortable supporting a colleague who
expresses behavioral health struggles and
directing them to appropriate resources.
    
I have discussed mental health challenges with
colleagues.     
I have applied the knowledge and skills I
learned to improve my own mental health.     
My personal mental health is improved since
participating in this program.
    
The overall culture toward mental health at
AFD is more positive since the program
began.
    
There is less stigma related to seeking out
mental health assistance at AFD.     
Recommendations for program improvement:
Additional comments:

Abstract (if available)

Abstract Since the year 2014, firefighters have taken their own lives at a rate higher than that of line-of-duty deaths. Commonly identified contributors to this tragedy include sleep deprivation, mental health illnesses such as post-traumatic stress disorder, and a high prevalence of substance abuse. Firefighter suicide is also likely underreported due to social stigma or a code of silence. With so many annual deaths, it is important to identify barriers to bringing improved mental health care to this population. This research was conducted in the Anytown Fire Department (AFD) in Arizona, which consists of 132 sworn personnel and four fire stations. The purpose of this research was to understand why the AFD did not have a mental health component aligned with its health and wellness program. It sought to identify if this was a result of gaps in knowledge, motivation, or organizational (KMO) barriers. Ten interviews were conducted with AFD staff. Interviewees were selected to create a representative sample of the department based on length of service, gender, and ethnicity. The data analysis determined whether the identified KMO influences were departmental assets or needs. All 10 influences identified were determined to be needs based on the interviews. The new world Kirkpatrick model was used to design and evaluate a comprehensive plan that would attempt to address these needs. This study begins to elucidate one area of a complex challenge facing the fire service today.

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Asset Metadata

Creator Zamboni, Dustin Leo (author)

Core Title Gaps in organizational mental health mitigation within the United States Fire Service

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2025-05

Publication Date 01/22/2025

Defense Date 01/14/2025

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag behavioral health,Burnout,compassion fatigue,firefighter,OAI-PMH Harvest,occupational health,PTSD,sleep disturbances,suicidality.

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Baer, Gamaliel (committee member), Yates, Kenneth (committee member)

Creator Email longhorns2627@gmail.com,zamboni@usc.edu

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Identifier etd-ZamboniDus-13773.pdf (filename)

Legacy Identifier etd-ZamboniDus-13773

Document Type Dissertation

Format theses (aat)

Rights Zamboni, Dustin Leo

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