A New Consensus Approach to Firefighter Behavioral

Health Urban Fire Forum, September 13, 2013, NFPA Headquarters, Quincy, MA

NFFF Everyone Goes Home® Project

The best way to honor fallen firefighters is to reduce the risks firefighters face in the performance of their duties

Initiated in 2004 with National Summit in Tampa, Florida

200+ fire service leaders created strategies to meet bold safety objectives

Produced 16 Firefighter Life Safety Initiatives

EGH Revisited, March 10, 11 and 12 – Tampa 2

1. Define and advocate the need for a cultural change within the fire service relating to safety; incorporating leadership, management, supervision, accountability and personal responsibility.

2. Enhance the personal and organizational accountability for health and safety throughout the fire service.

3. Focus greater attention on the integration of risk management with incident management at all levels, including strategic, tactical, and planning responsibilities.

4. All firefighters must be empowered to stop unsafe practices.

5. Develop and implement national standards for training, qualifications, and certification (including regular recertification) that are equally applicable to all firefighters based on the duties they are expected to perform.

6. Develop and implement national medical and physical fitness standards that are equally applicable to all firefighters, based on the duties they are expected to perform.

7. Create a national research agenda and data collection system that relates to the initiatives.

8. Utilize available technology wherever it can produce higher levels of health and safety.

9. Thoroughly investigate all firefighter fatalities, injuries, and near misses.

10. Grant programs should support the implementation of safe practices and/or mandate safe practices as an eligibility requirement.

11. National standards for emergency response policies and procedures should be developed and championed.

12. National protocols for response to violent incidents should be developed and championed.

13. Firefighters and their families must have access to counseling and psychological support.

14. Public education must receive more resources and be championed as a critical fire and life safety program.

15. Advocacy must be strengthened for the enforcement of codes and the installation of home fire sprinklers.

16. Safety must be a primary consideration in the design of apparatus and equipment.

16 Firefighter Life Safety Initiatives

Firefighters and their families must have access to counseling and psychological support.

Elements of FLSI 13 Strategic Plan

Structured knowledge translation processesConsensus group model matching:

Leading research groups in specific topic areasSubject matter experts in best practice domainsFire service constituency organizationsThree working groups contributed to generating these proposalsTraumatic Exposures in the WorkplaceMember Assistance ProgramsPeer Support Practices

Research and PracticeNational Center for PTSD National Institute for Occupational

Health and Safety (CDC) National Crime Victims Research and

Treatment Center (MUSC)USUHS Center for Study of Traumatic

StressEmployee Assistance Professional

Association Firefighter Health Research Group

Fire Service

International Association of Fire Fighters

International Association of Fire Chiefs

National Volunteer Fire Council

National Fire Protection Association

National Association of EMS Physicians

North American Fire Training Directors

FLSI 13 Consensus Project

No

No

No

No

After Action Review

Stress First Aid for Fire and EMS Personnel

Trauma Screening

Questionnaire Behavioral Health

Assistance Program

Cognitive Behavioral Therapy

Peer Support

Curbside Manner: Stress First Aid For the Street

Curbside Manner:Stress First Aid for the Street

• For use by Fire-EMS personnel in service encounters

• Evidence supported best practice for immediate assistance

• Based on military Combat and Operational Stress First Aid

• Seamless delivery in performance of duties

Curbside Manner:Stress First Aid for the Street

Curbside Manner: Stress First Aid for the Street

• Add an extra dimension of service and care

• Not just a “feel good” approach

• Based on 2 decades of research on what helps people recover from crisis events

Objectives of Curbside Manner

Establish a respectful, helpful connectionRestore/support a sense of safetyCalm and orient distressed individualsConnect to sources of social supportImprove ability to address critical needs/concernsHelp limit self-doubt and guilt

Curbside Manner Core Actions

1 Cover

2 Calm

3 Connect

4 Competence

5 Confidence

Available on the Fire Hero Learning Network• Online CE program• CE package for download:• PowerPoint (slides and video)• Instructor Guide• Student Manual

Military After Action Review (AAR)

• Backbone of the operational culture

• Monitors capacity, enhances capability, maintains accountability

• Done at every level for every operation—large or small, simple or complex, critical or routine

Advantages of AAR Hot Wash

• Meaningful mechanism for review/questions

• Supports on-going learning environment

• Focuses on professional impact

• Often relieves anxiety and uncertainty

• Permits safe transition into emotional impacts if indicated

Foundation for Effective AAR:

Five simple questions after every activity:– What was our mission?– What went well?– What could have gone better?– What might we have done differently?– Who needs to know?

The Unit Level “Hot Wash”

The best company officers have been doing this for years . . .

• “Kitchen table review”• “Tailboard critique”• Informal firehouse learning is an honored

fire service tradition

AAR, like ICS, provides a way to ensure a consistent, reliable benefit

Available on the Fire Hero Learning Network

• Online CE program• CE package for download:– PowerPoint (slides and video)– Instructor Guide– Student Manual

• Support materials

Trauma Screening Questionnaire

Brewin, Rose, et al. (2002): • Four to six weeks post impact• Arousal and re-experiencing cardinal indicators• Any six of ten symptoms endorsed as “twice or more in

past week”• Those showing positively referred for full evaluation• Specificity >.86; sensitivity >0.93 • Overall efficiency > 0.90

Available from the NFFF/EGH • Print and electronic copies of TSQ

for download• Pursuing funding to create apps to

assist individuals, family, coworkers, and peer support personnel in identification and referral

Behavioral Health Assistance Programs

• Impacts can be wide ranging

• Often brings other issues to surface

• Providing clear guidance, service standards, and outcome expectations

First working group determined that significant changes were required to ensure that programs were able to deliver intended outcomesEAP researchers and practitioners worked with fire service organizations to identify best practices and how to implementSpecific desire to strengthen and clarify

Behavioral Health Assistance Programs

Principal Needs from BHAP

• Accessible resource for problems and issues• First point of access for assessment and referral• Consistency of model, service, and performance• Clear service objectives, treatment standards,

and outcome expectations• Consensus recommendations for revisions to

NFPA 1500 (Chapter 11)

Available from the NFFF/EGH • Model template for Fire Departments to

assist with developing Request for Proposals• Examples for Scope of Work • Help for vendors in using FLSI 13 resources to

built responsive BHAPs

When Clinical Intervention is Indicated

• Treatments typically used in routine counseling are rarely effective

• Cognitive Behavior Therapy (CBT) with graded exposure holds best evidence

• Not widely practiced at levels of care ordinarily available to firefighters

• How can we help those who treat our personnel acquire critical skills?

Helping-Heroes.org

Targeted at educating providers of treatment for firefighters on evidence-based protocols for behavioral activation, in-vivo & imaginal exposure, & relaxation

10 education modules + 1 training & website evaluation module

Each module contains pre- & post- knowledge check questions, videos demonstrating application of technique, & videos of answers to common questions

Stress First Aid for Fire and EMS Personnel

We become most proficient at things we do consistently

We seek consistency where performance is central to our values

We default to those consistent practices under duress and demand

Everyday use of CM-SFA for the Street builds reliable, consistent skills that provide the foundation for

structured peer support assistance that reflects current

evidence supported best practice

Stress First Aid Principles

• Based on a careful review of the empirical literature from many fields, as well as from the broad experiences of experts involved in work on disasters, terrorism, war and other mass casualty situations

• Stress First Aid was adapted from the Stress and Combat Operational Stress First Aid model for Marines Corps and Navy personnel

Functions of Stress First Aid

• Reduce the risk for stress reactions

• Monitor the stress of fire and recue personnel

• Recognize individuals who are reacting to a wide range of stressors

• Provide a spectrum of one-on-one interventions

• Monitor progress of recovery

• Bridge individuals to higher levels of care as needed

Knowledge/Skills for Every Member of Organization

• Recognize when a co-worker may have a stress injury• Know how to break the code of silence that

surrounds stress injury• Know at least 3 trusted support resources that could

be used to help a co-worker

Stress Continuum ModelREADY

(Green)REACTING

(Yellow)INJURED

(Orange)ILL

(Red)

DEFINITION Optimal functioning Adaptive growth WellnessFEATURES At one’s best Well trained and

prepared In control Physically, mentally, and

spiritually fit Mission focused Motivated Calm and steady Having fun Behaving ethically

DEFINITION Mild and transient

distress or impairment Always goes away Low riskCAUSES Any stressorFEATURES Feeling irritable,

anxious, or down Loss of motivation Loss of focus Difficulty sleeping Muscle tension or other

physical changes Not having fun

DEFINITION More severe and

persistent distress or impairment

Leaves a scar Higher riskCAUSES Life threat Loss Moral injury Wear and tearFEATURES Loss of control Panic, rage, or

depression No longer feeling like

normal self Excessive guilt, shame,

or blame

DEFINITION Clinical mental disorder Unhealed stress injury

causing life impairmentTYPES PTSD Depression Anxiety Substance abuseFEATURES Symptoms persist and

worsen over time Severe distress or social

or occupational impairment

Organizational Environment

• Fire Service personnel work as teams with leaders • Chain of command• Leaders can apply the principles of SFA to:– Reduce unnecessary stress– Recognize when an individual or unit has stress injuries– Activate early resources based on need not event

SFA Provides a Framework for Response

• Flexible, multi-step process• Timely assessment• Peer and leader response to stress injury• Goals:– Preserve life– Prevent further harm– Promote recovery

Available from the NFFF/EGH • Awareness, Operations, and Technician

level training • Regional Train the Trainer• CE packages:• PowerPoint• Instructor Guide• Student Materials

• Ongoing support• Crisis assistance

Good News About Initiative 13 Model

Information presented is:• Fully consistent with all elements of Chapter

11 (Behavioral Health Assistance Program) and Chapter 12 (Occupational Exposure to Atypically Stressful Events) of NFPA 1500

• Fully consistent with major authoritative guidelines regarding response to potentially traumatic events

Questions?

Thank You!