SLEEP COACHING FOR UNIFORMED

Sleep Coaching for Uniformed Firefighters

Melanie Anon
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Melanie Anon is a registered nurse per diem with Banner Staffing Services at Banner Health.
She has no known conflict of interest to disclose.
Correspondence should be addressed to Melanie Anon, Edson College of Nursing and Health
Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ 85004.
Email: mfdufek@asu.edu

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Abstract
Sleep deprivation is linked to poor mental and physical health outcomes for professional
firefighters. The importance of sleep hygiene practices and health promotional activities may
increase the amount of quality sleep firefighters get on their days off. As the adverse outcomes of
circadian misalignment due to sleep deprivation becomes more apparent in firefighter wellbeing,
the need for a sleep health program becomes more evident. The purpose of this paper is to
examine and assess the effects of a sleep health program for firefighter wellness. Research
emphasizing the relevance of poor health outcomes related to sleep disturbances is prevalent in
the literature. The findings have prompted the development of an evidence-based sleep coaching
program for firefighters in a local fire department guided by The Cognitive Behavioral Therapy
Model (Brewin, C.R., 1996). and a Knowledge-to-Action process framework for evidencebased-practice (Graham et al., 2006).
Keywords: firefighters, sleep, mental health, and sleep deprivation

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Thank you to my mentor Dr. Wayne McIntosh who guided me along the way during
intense moments of the program. Thank you to Dr. Patricia Haynes for your professional
collaboration, knowledge, and time. Thank you to my parents, whose love, support, and guidance
is with me in whatever I pursue. For my husband Dariel and to my son Kai, I could not have
endured this four-year journey without your continuous love and support; to which I am forever
grateful. The love and joy you’ve brought to my world helped me sustain the tedious process of
this degree. This is all for you. Completing this program was my dream. Thank you all for being
my inspiration to be a great scholar, mother, wife, and daughter.

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Background and Significance
Sleep Deprivation in Firefighters
The role of proper sleep health has become an important factor in health maintenance and
longevity. Most firefighters are not meeting the recommended national sleep health initiatives
due to work interruptions throughout the night and demanding schedules. Typical shift schedules
for firefighters include 24 hours on followed by 48 off or 48 hours on and 96 hours off; and other
variations. This schedule makes firefighters more vulnerable to sleep-related physical and mental
health conditions (CDC, 2018). The physical and mental demands of a firefighting career
require a focus on holistic health to increase longevity and quality of life, especially on days off
when recovery time is crucial.
The firefighter population is at risk for specific health ailments; both different from, and
comparable to other careers in public safety. For example, sudden cardiac death (SCD) is the
leading cause of on-duty deaths for firefighters, and those with preexisting conditions such as
coronary artery disease, elevated blood pressure, and high cholesterol have an increased risk
(CDC, 2018). Firefighters work challenging jobs due to the frequent use of heavy machinery
equipment, exposure to harmful materials, and performing live saving maneuvers in dangerous
situations. This increase in stress may impact blood pressure, thus facilitating cardiac problems
in the future (CDC, 2018).
The impact of fatigue on cognitive and motor function mimics those impacted by alcohol
intoxication. Therefore, injuries, motor vehicle accidents, reduced response time, and reduction
in critical thinking skills may impact both firefighters and public safety in similar ways that
alcohol does (CDC, 2018). Firefighters who experience shiftwork fatigue they are at higher risk
for work injuries; especially those who work longer than 24-hour shifts (CDC, 2018).

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Although the firefighting career consists of both male and female employees, it is highly
dominated by the male population. Specific concern of an imbalanced circadian rhythm in men
includes low testosterone levels, which may increase adversities related to fatigue, mood,
personal intimacy, and work performance, especially when physical demand is crucial (Pacheo,
2020). In essence, optimal physical and mental health are vital in a career where much physical
demand and resiliency is required.
Aside from physical health concerns, the mental health aspect of firefighters is equally
important. The effects of shiftwork fatigue in addition to frequent exposure of occupational
hazards, dangerous situations, physical demand, and human suffering may exacerbate the effects
of posttraumatic stress symptoms, alcohol use, sleep disturbances and suicidality (CDC, 2018).
Mental health is a stigmatized subject within the firefighter community that is not openly
discussed, and seeking help is avoided (APA, 2019). Many firefighters may face mental health
challenges that can be exacerbated by sleep impairment or initiate further sleep disturbances.
Purpose and Rationale
Firefighters are susceptible to sleep deprivation and the negative outcomes associated
with shift work disorders which impact both physical and mental health. The increased demand
within the firefighting workplace environment remains a safety concern when fatigue exists.
Injuries and poor health outcomes are facilitated by exhaustion and lack of sleep (Center of
Disease Control, 2018). Chronic fatigue from shift work disorders may exacerbate existing
mental health disorders or precipitate the development of them, and lead to poor physical health
outcomes (AASM, 2021). The purpose of this paper is to establish an increased awareness in the
firefighter community and promote healthy sleep habits through a sleep coaching intervention.

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Problems with Shiftwork
The industrialized world will continue to require 24-hour shifts as a necessity for public
safety and health, as well as commercial reasons. However, employees working these inevitable
shifts are at risk for developing shift work disorder (SWD). Shift work disorder is common
among healthcare professionals, truck drivers, military personnel, airline employees, and
industrial jobs. Although night shift and long work hours are inevitable for public safety, it may
disrupt normal sleep habits (CDC, 2018). Shift work schedules include early-morning shifts,
night shifts, overnight shifts, and rotating shifts; all of which disrupt the natural human circadian
rhythm leading to adverse mental and physical health outcomes (AASM, 2021). SWD is a
condition defined by a circadian rhythm misalignment resulting in excessive daytime sleepiness
at times when being tired is not desired. Along with multiple mental and physical health
consequences, SWD is associated with a decrease in work performance, and an overall
diminished quality of life (Wickwire et al., 2017). This disruption is often due to erratic sleep
schedules, which obligates workers to realign their circadian rhythm during their days off.
The average adult requires 7-9 hours of sleep and the American Academy of Sleep
Medicine (AASM) cautions adults who sleep less than 7 hours on a regular basis, and shift
workers that are defined as those who work non-standard work schedules, or those who work
permanent or intermittent night schedules. Those who do not meet sleep initiatives are at
significant risk for poor health outcomes including impaired immune function, metabolic
syndrome, cardiovascular disease, depression, anxiety, and increased risk of death (AASM,
2021). Practicing healthy sleep habits is important for mental health, physical recovery, and
metabolic balances. According to the CDC (2018), nightshift workers are at increased risk for

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cardiovascular disease, cancer, obesity, type 2 diabetes, a weakened immune system, depression,
and anxiety due to consistent disruption in circadian rhythm.
Firefighter shifts may vary depending on each department need, call volume, distance
from firefighter residences, and more. The days off in between shift schedules for example, are
not always properly utilized by firefighters, and many of them tend to personal obligations or
second jobs rather than sleep recovery. In addition, some firefighter schedules are harder to
readjust circadian rhythm to, especially when the recovery day is also the day before next shift.
This dilemma heights the need for adequate recovery time in between days off to ensure safety of
both the firefighter and the public.
The Importance of Sleep Hygiene
Frequent night awakenings within the fire service are inevitable; however, management
of personal sleep hygiene through educational programs may provide more opportunities for
quality sleep and rest. According to Barger et al., (2016) sleep health programs and awareness
programs are currently required in other shift work careers since as railroad workers, truckers,
aviation employees and nurses. When firefighters were given the opportunity to participate, at
least three-quarters joined and 46% reported behavioral changes that may have a lasting effect
(Barger et al., 2016). Behavioral change is a lasting skill that firefighters can use to solve future
problems. Some of the reported behavioral changes that firefighters reported included taking
their blood pressure once a week after fires, drinking half the amount of normal coffee, and
taking more naps (Barger et al., 2016). A sleep health program is shown to be effective and
feasible to implement to increase knowledge of sleep health and improve sleep behaviors both on
and off shift. These programs can easily be implemented in person or online leading to reduced
sleep related morbidity and mortality among firefighters (Sullivan et al., 2017). Although sleep

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health programs may be easily implemented, some firefighters report feeling overwhelmed by
educational programs due to scheduled training and job duties. Peer leaders recommend making
these sleep health programs part of a mandatory wellness program, or flexible around firefighter
schedules to be most effective (Barger et al., 2016). Each fire department have unique challenges
and opinions may differ among firefighter employees or department culture. The CDC (2018)
recommends gathering existing knowledge within an organization to determine specific priorities
to address. Health and safety concerns may be efficiently addressed through implementation of
pilot testing survey materials, educational materials, safety training materials, and or other
research-based methods tailored to the specific organizations’ work environment (CDC, 2018).
Firefighters Without Sleep Coaching
Firefighters acknowledge unpredictable disruptions and adverse events to occur during a
24-hour period as part of expected duties of the job, including exposure to imminent danger.
Firefighter culture promotes resiliency as part of the required strength and endurance needed to
serve as public safety figures. Frequent service calls with hazardous situations may subject
firefighters to sleep deprivation, physical exhaustion, and increased stress from repetitive
exposure to human agony (CDC, 2018). Personal resiliency is subjective; yet resiliency impacts
a firefighters’ ability to recover from post-traumatic stress symptoms (PTSS) and cope with
difficulties (Wickwire et al., 2017). Highly resilient individuals report increased positive
emotions, a greater sense of control, and better physical and mental health; while those with
lower resiliency experience an increase in posttraumatic stress symptoms (Wickwire et al.,
2017). Since resiliency is dependent on the individual, proper coping skills tailored to each
person are important to overcome hardships. Unfortunately, the firefighting culture limits

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uniformed firefighters from seeking proper self-care and addressing mental health needs due to
the stigma of expected resilience without help.
Posttraumatic stress severity (PTSS) is significantly, positively associated with alcohol
use for coping with adverse events. Similarly, increased sleep disturbance was significantly,
positively associated with alcohol use for coping reasons related to PTSS (Smith et al, 2018).
Hence, stress and sleep may create a vicious cycle also known as insomnia. Since some people
lack adequate coping skills to regulate stressful circumstances, they may internalize conflicts
leading to emotional turmoil. Emotional unrest may result in hyperarousal and problems with
sleep. Difficulties with sleeplessness may in turn intensify emotional arousal; thus, creating a
vicious cycle between alcohol use and worsened sleep quality (Smith et al., 2019).
Although occupational stress, exposure to trauma, depression, and anxiety all correlate
with sleep disturbance, the strongest correlation with sleep deprivation was an increased suicide
risk (Serrano et al., 2020). Pre-employed firefighters reported less sleep disruption than their fulltime employed counterparts, however, the strongest factors associated with sleep disruption
included depression, anxiety, and social support (Lim et al., 2020). Firefighters may find
relaxation challenging in an action-packed career and the importance of rest may be minimized.
Circadian disruptions are expected within the firefighting career due to the nature of
frequent emergency action required throughout the night. Although daytime naps may provide
short-term benefit, they are not substantial to replace long-duration sleeping (AASM, 2021).
When normal cycles of the sleep-wake rhythm are often interrupted, it may take two days to
restore a normal rhythm, and four to restore a severe dysrhythmia (Billings & Focht, 2016). For
example, a 24on/48off shift allows for circadian rhythm to return to a normal pattern only if no
further disruptions occur and sleep prioritization is utilized (Billings & Focht, 2016). The ability

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to gain adequate sleep within 48 hours is subjective to the individual and their ability to sleep
without unwanted impairment.
Barriers to Adequate Sleep on Days off
Although most people who are fatigued come home to sleep, some firefighters work
second jobs or pick-up overtime for additional income during their days off. Other firefighters
tend to members of their family, or children who need care during the days off. This can further
impair firefighters from adequate recovery time when errands and family obligations take
priority. A study shows firefighters who added an additional 24-hour shift as overtime increase
the risk of furthering sleep deprivation and exhibited signs of high diastolic blood pressure
(DBP); compared to those who reported their standard assigned schedule (Choi & Dobson,
2016). A cross-sectional study examined the association of obesity, hypertension, and sleep
apnea in firefighters with increased left ventricular mass. According to the study, BMI is the
strongest predictor of LV hypertrophy and increased cardiac mass. This is believed to be related
to hypertension and sleep apnea resulting from metabolic disorders with weight gain (Korre et
al., 2016). Sleep deprivation further precipitates the development of metabolic syndromes,
cardiovascular risk, and weight gain (CDC, 2018). This vicious cycle of cardiac strain is a result
of insufficient rest periods, continuous work-related stressors, or fulfilling obligations rather than
using rest time.
Lack of Sleep Coaching or Wellness Programs
Currently, health management programs geared toward firefighters are limited. Health
management programs and screening may be helpful for firefighter wellness. Firestrong
provides basic online information regarding sleep and mental health for specific Arizona
departments; yet it is uncertain if fire fighters regularly utilize these resources (FireStrong,

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2021). A health clinic known as Heart Fit for Duty offers cardiovascular wellness screening,
fitness, nutrition and health screenings to Firefighters, EMS, Police and Military patients.
However, this website is lacking information about sleep hygiene or self-screening opportunities
for sleep disorders (Heart Fit for Duty, 2021).
Firefighting training academies within the valley offer limited educational training while
focusing on physical endurance. Current wellness programs and PTSD prevention programs are
initiated briefly during firefighting academies for new hires. However, the lasting effects of these
programs on behavioral change or sleep habits are currently unknown, and refresher courses are
not provided (City of Glendale, 2019). The literature review mentions a general lack of
intervention and health promotion in firefighters for sleep hygiene; and suggest more attention is
given to this population of first responders (Barger et al., 2016).
Scottsdale Fire Department
The city of Scottsdale is known for its clubs, tourism activities, entertainment districts,
and shopping. This busy commercial hub increases visitors and residential demand causing the
frequent use of emergency services. A large Fire Department located in Scottsdale is the third
largest and busiest department in the Valley. They report 275 sworn firefighter employees, with
more than 20,000 incident calls for 2020 (City of Scottsdale, 2021). The number of emergency
calls within busy stations further subjects’ firefighters to frequent awakenings in the middle of
the night; thus, triggering the negative effects of sleep disruption. The fire chief of this
department changed the original 48/96 schedule (48 hours on shift, and 96 hours off) to a 24/48
(24 hours on shift, and 48 hours off) in 2014 due of concerns related to poor patient outcome,
delayed response times, or error related to fatigue. The interest in this problem led to an
examination of up-to-date evidence to determine the most effective interventions for sleep

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hygiene. This literature review has initiated a clinically relevant PICOT question, “In firefighters
(P), how does a sleep coaching program (I), compare to current education (C), impact sleep
disturbance (O) over 30 days (T)”?
A Hopeful Future
The initiation of sleep wellness programs may have lasting impacts
on firefighters’ behaviors. Firefighters who participated in a sleep health program (SHP) reported
the important information to be helpful and lead them to initiate positive behavioral changes
within the department after completion (Barger et al., 2016). Workplace wellness programs that
provide firefighters with sleep health education and sleep disorder screenings may also reduce
the amount of workplace injuries and disabilities (Sullivan, 2017). Firefighter education may
include strategies for practice of better sleep routine, limiting alcohol use, prioritizing sleep, and
time management for personal obligations. Other considerations may include mindfulness or
relaxation techniques. Firefighters who practiced the act of mindfulness reduced their stress
related sleep disturbances and overall risk for suicide (Serrano et al., 2020). Sleep coaching may
have impact on long-term behavioral changes surrounding sleep practices.
Search Strategy
A thorough review of current evidence was conducted in a database search to answer the
PICOT question “In firefighters (P), how does a sleep coaching program (I), compare to current
education (C), impact sleep disturbance (O) over 30 days (T)”? Three databases were
expansively searched for recent and relevant materials to the topic of fire fighters and sleep
deprivation. These databases are known for their reliability and scientific contributions within
the medical field; thus, yielding dependable results best suited for practice change. Three
databases were utilized – PubMed, EBSCO Host, and ProQuest.

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Databases were searched using key terms that addressed all components of the PICOT
question; the combination of these terms included: firefighters, sleep, health, mental health,
wellness, sleep deprivation, and insomnia. Key terms for the intervention sleep health program
narrowed the search, so broad terms such as health, wellness and sleep yielded better results.
Filters were applied for publications between 2012 to 2021 and full text articles. The Boolean
phrase was used to broaden the search.
The initial search terms for PubMed included firefighter, sleep habits, sleep deprivation,
and quality sleep, and only yielded 5 results. To widen the search results, these terms were
narrowed down to firefighters, sleep habits, and sleep deprivation; this search yielded a total of
27 results. To further expand the results, the terms were limited to firefighters, sleep, and health,
which generated 129 results without filters.
The initial search terms for EBSCO Host included firefighters, mental health, and sleep
which generated 0 results. Search terms were narrowed down to firefighter and sleep produced
64 results. Filters added to these search terms included publication dates narrowed to 2012-2021,
and full text, which further narrowed the results to 10.
Lastly, the initial search terms for ProQuest were firefighter and sleep, which produced
74 results. The search terms firefighters and sleep deprivation were added instead of sleep, which
yielded 0 results. The search terms firefighters and sleep deprivation were then exchanged for
firefighters and insomnia, which resulted in only 5 results. The best terms for this data base with
the highest results were firefighters and sleep, with filters for full text and publications between
2012-2021 applied.
After reviewing titles and abstracts of articles based upon the inclusion criteria, 29
relevant articles were selected. Full text articles were retrieved for all 29 articles, which were

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then evaluated with a rapid critical analysis checklist to narrow articles to the last 10 highest
quality studies. These included two randomized control trials, five cross-sectionals, one systemic
review, one meta-analysis, and one cohort study. Exclusion criteria included any articles
unrelated to impacts of sleep deprivation, articles generalized to first responders and shift work,
or any articles before 2016.
Critical Appraisal & Synthesis of Evidence
The quality and level of evidence was determined by use of the Melnyk and
Fineout-Overholt’s (2015) rapid critical appraisal tool. Cross-sectional studies are a lower level
of evidence due to the inability to rule-out bias in self-reporting screening tools. However, this
study design is favored for its ethical approach when studying the firefighter population, since
certain interventions cannot be easily implemented within a fire department or home setting. A
cross-sectional evaluation tool was used to determine the strength of cross-sectional evidence
regarding sleep health, mental health, physical health, and the application of a health promotion
program (Joanna Briggs Institute, 2017).
The study participants were predominantly male firefighters between the ages of 30-40
years old with previous work experience. The exception of one study that focused on the
difference between newly employed firefighters vs. employed. Most of the studies were
conducted in various settings such as the workplace, off-site health clinics, or online; and all the
studies utilized screening tools. The studies were conducted both in the United States and other
countries such as Thailand, Korea and Japan. Appropriate screening tools were used to measure
self-reported sleep quality, mental health symptoms, demographic information, and determine
observational relationships between variables. Less than half of the studies contained a sample
size greater than 1000 people, and more than half of the others contained a smaller sample size

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below 600 people. Additionally, 6 of the 10 studies focused on a health promotion intervention
lasting between 15-160 minutes over the duration of a single session to 5 sessions. The other 4
studies were included for their significance in demonstrating the relationships between mental
health, physical health, and sleep deprivation.
Conclusion
The importance of a sleep health promotion program for firefighter wellness is clear,
and it may provide firefighters with tools to improve a holistic physical and mental wellbeing.
The quality of life in firefighters is an important factor for health maintenance and longevity
within a career that is physically and mentally demanding. Most importantly, firefighters who are
well rested are less likely to experience workplace injury and improve patient outcomes with
improved cognitive attention. Sleep health promotion programs grant firefighters the opportunity
to receive evidence-based skills that enhance awareness of poor sleep hygiene and provides the
tools for long-term behavioral change. Effective sleep health promotion programs should
include a variety of sleep coaching methods with information that firefighters may modify to
meet their unique needs.
The topic of sleep health for firefighters is lacking within the firefighter community,
departments, and outreach programs. By providing firefighters a tailored sleep coaching program
with resources, it may reduce adverse physical and mental health outcomes related to SWD. The
included studies contain evidence that displays the ease of applying a health promotion program
within various settings and is cost effective. However, mental health and related stigmas within
the firefighter community should be considered, and any educational material should be designed
with a communication style that firefighters are receptive to.

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Theoretical Framework
Cognitive Behavioral Therapy (CBT) is considered an integrative theoretical framework
which consists of interworking parts. This framework distinguishes therapy interventions which
are targeted at specific disorders and contains interventions that modify conscious beliefs and
representations from memory (Brewin, C.R., 1996). An individual’s perception or spontaneous
thoughts may influence their emotional and behavioral reactions to a certain circumstance.
However, the theory of CBT is to assist patients to identify and correct their thinking, so it
closely resembles reality to decrease distress and increase overall functioning (Beck Institute,
2021).
In the 1970’s cognitive therapists argued with the theory that patients are entirely at the
mercy of their conditioning history and conscious thoughts. Cognitive therapists have argued that
techniques based upon a CBT approach have been successful in generalized problems such as
Generalized Anxiety Disorder (GAD), depression, and personality disorders; since it is focuses
on identifying unconscious representations, changing conscious beliefs, teaches coping skills,
and modifies less-accessible underlying structures within the memory (Brewin, C.R., 1996). The
5 stages of this model include 1) Situation, 2) Automatic Thoughts and Images, 3) Reaction, 4)
Emotional, 5) Behavioral, and 5) Physiological. Firefighters who experience sleep disruptions
may unconsciously attribute them to certain psychological beliefs or reactions that may require
restructuring through therapy. The CBT theoretical framework is used as guidance for behavior
change which may positively impact sleep by decreasing disruptions, changing routine, and
modifying beliefs surrounding sleep habits and routine.

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Implementation Framework
Most individuals who hold internal motivation to contemplate a lifestyle change have
likely considered the pros and cons of changing problem behaviors. Using information about
sleep and providing a CBT-I intervention that is delivered in manageable sections from provider
to individuals, is what makes the Knowledge-to-Action (KTA) process framework adaptable for
firefighters who work hectic schedules (Graham et al.,2006). The model design includes
informing and assessing for efficacy of the knowledge implemented, making it helpful to
determine both efficacy and feasibility within the fire department among firefighters reported
self-evaluation tools. The KTA model is flexible and encourages interventions to be tailored to
suit the needs of specific audiences or current circumstances.
The CBT-I intervention will be tailored to meet the specific sleep impairments
within each individual firefighter. This model correlates closely with the core of the
intervention, which is a tailored sleep coaching program best suited for individual
firefighters (Graham et al., 2006). The KTA model describes stages at which knowledge can be
applied, evaluated for effectiveness, and reproduced, which is ideal for stakeholders who wish to
utilize aspects of the project for long-term changes and maintenance of change (Graham et al.,
2006). Firefighters will be asked to complete an end survey to determine feasibility of the
program, which may help stakeholders make final decision in participation in future
interventions, as well as what aspects of the program need improvement. It is important to
consider that firefighters as individuals hold different health risks, and this variation may be
dependent on age, lifestyle, years on the job, and current health status. Therefore, it is important
to tailor the education of potential risks, threats, and solutions to resonate with the needs of an
individual, rather than one mass generalized group.

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An exchange of knowledge delivered in manageable sections from a healthcare provider
to individuals, teams, or healthcare organizations, makes the Knowledge-to-Action (KTA)
process framework (See Appendix G) adaptable for a variety of settings (Graham et al., 2006).
This model is designed to inform and assess the efficacy of knowledge retained by the individual
implementing it. The KTA model is flexible and encourages interventions that are tailored to suit
the needs of current circumstances and specific audiences. Additionally, the model evaluates the
appropriateness of the specific knowledge that is delivered for sustained use. The KTA model
has a broad focus to ultimately enhance health status, which is suitable to meet the needs for the
development and delivery of an evidence-based education to the firefighting community
(Graham et al, 2006). This thorough research, and evaluation of evidence that has been
examined, condensed, and refined, makes it useful for important stakeholders. The KTA model
describes stages in which knowledge can be reproduced, applied, and evaluated for effectiveness
(Graham et al., 2006). Using evidence to describe sleep deprivation and the negative effects
associated with a lack of sleep, may be paired with sleep hygiene practices to promote wellness
among the firefighter community.
Setting and Stakeholders
This large Fire Department in Scottsdale is a city funded organization that reports 275
sworn firefighters currently employed and reports over 20,000 service calls for 2020 (City of
Scottsdale, 2021). The city of Scottsdale is known for its entertainment district which attracts a
high volume of visitors and residents within the community; thus, increasing the need for
emergency services. The current Fire Chief expressed concern for sleep deprivation among his
firefighter counterparts. In the past, he has initiated two schedule changes to improve outcomes
from the effects of firefighter fatigue on patient care, safety, firefighter health, and other work-

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related outcomes. Despite these changes, the emphasis of sleep health is lacking within the
firefighter community where excellence and safety is expected.
The Fire Chief agreed that an intervention to promote sleep health may be beneficial in
multiple aspects and delegated the assistant fire chief to continue involvement with the project.
The assistant Fire Chief oversees management of meeting times, project goals, and feasibility,
and recruitment of other key stakeholders or members of interest. Recently, the assistant fire
chief introduced a professional collogue involved in a similar intervention with this department.
A professor of clinical psychology and researcher in sleep health at the University of Arizona,
Dr. Patricia Haynes, plans to recruit firefighters to implement a long-term intervention with goals
improve sleep quality. This intervention will not be implemented until 2022 and using this
project as a small pilot will be useful for both the organization and the other stakeholder. The
professional collaboration to ensure both interventions align will provide the department the
most efficient, tailored, effective, and useful intervention for firefighters. Additionally, this
project alignment will provide ideal outcomes for the agency, firefighters, and all stakeholders
involved. Synchronized teamwork between two professionals can provide a better experience for
firefighters who volunteer to participate and increase the likelihood of future engagement and
completion rates.
Participants and Recruitment
Upon acceptance of the project proposal from the Fire Department and IRB approval,
firefighters were recruited through word-of-mouth by the Fire Department Union President via
their work e-mail. Those who were interested in sleep coaching sent a response e-mail as implied
consent to participate. The inclusion criteria incorporated uniformed firefighters who reported a
sleep disruption and a desire to improve their quality of sleep. Firefighters of any age or gender

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were considered and all volunteers were asked to express interest in participation by a
predetermined deadline. Exclusion criteria included firefighters who do not wish to participate,
those who were not concerned about their sleep quality, those who were not literate in cellphone
or telemedicine use, and those who do not complete the full intervention. Since the sample size
was a total of 2 firefighters, no volunteers needed to be turned away.
Firefighters were provided the pre-survey screening tool to identify which problem area
is likely the cause of poor sleep quality and obtain demographic data. A total of 6 firefighters
completed the pre-survey, and only 2 scheduled the intake.
Planning and Intervention Methods
The American College of Physicians has strongly recommended CBT-I as the first-line
treatment for insomnia disorders, regardless of the fundamental etiology (Quaseem et al., 2016).
Additionally, a sleep coaching problem based upon CBT-I is useful and feasible over the phone.
Upon receiving implied consent, 3 surveys were e-mailed to each firefighter using survey
monkey to determine eligibility and obtain basic demographic data. Survey monkey was used to
hold data. An individual participant ID number was created in the demographic survey to
maintain privacy of all responses. Firefighters completed an initial screening tool to determine
the presence of a sleep related impairment or disturbance using the Patient-Reported Outcomes
Measurement Information System (PROMIS) Sleep Disturbance Assessment (SDA) and Sleep
Related Impairment (SRI) screening tools, as well as a demographic data tool. A total of 6
firefighters completed the pre-surveys and only 2 of the 6 participants schedule an intake to
move forward in the process. An intake meeting was scheduled via e-mail over the phone. An
assessment sheet from the Veteran’s Affair CBT-I Manual was used to gather information about
sleep schedule, problem areas, sleep practices, and sleep hygiene. During the intake, firefighters

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were instructed to download a user-friendly sleep diary app to gather sleep trend, then export via
e-mail in excel format prior to the next session. The sleep diary was not a data tool, but rather a
tool to assist in tailoring the intervention individually. The firefighters provided verbal consent to
record sessions with an electronic recording device that was monitored by Dr. Patricia Haynes to
provide professional feedback and assist in tailoring a plan.
During week 2 the intervention consisted of Cognitive Behavioral Therapy for Insomnia
(CBT-I) sleep coaching session 1. The first sleep diary was reviewed via e-mail and shared with
Dr. Haynes prior to session 1 to identify problem areas of the firefighter’s sleep patterns, and to
shape the session. Tailored sleep sessions will ensure firefighters are gaining specific skills to
meet their individual sleep challenges.
Week 3 consisted of a follow-up of session 1, and to review the next sleep diary. The
purpose of session 2 is to make any adjustments to the suggested intervention, answer questions
from session 1, and review the sleep diary one last time. Recordings from the previous session
were shared with Dr. Haynes, and adjustments were made as needed to the new sleep schedule.
Any additional questions, concerns, or comments were considered at this time to enhance the
retention of newly acquired skills. Upon completion of the intake, session 1, and session 2,
firefighters then completed a post-survey via e-mail to measure sleep changes in the PROMIS
SRI and SDA. Additionally, a feasibility was used to evaluate the opinion of the program, the
likelihood of using the program again, and the likelihood of continuing to use the skills learned
in the future.
Barriers include: 1) The fire community stigma of ‘non-vulnerability’ and honest selfdisclosure, 2) Self-reporting scales are subjective to the patient and do not directly measure
physiological data, 3) Firefighters may delay sessions or drop-out prematurely before adequate

SLEEP DEPRIVATION IN FIREFIGHTERS

22

data is collected due to hectic work-life balance and schedules, 4) Unexpected problems with
technologies used for education, coaching sessions, and data collection, 5) Bias information may
be given to assist the sleep coach in completing the project.
Budget
The nature of this project is to be as cost effective as possible. The entire intervention
occurred online or over the phone which did not add any extra cost other than routine phone and
internet bills. The design of this project will be used on an at home computer with Microsoft
word and a PDF viewer, therefore, no materials or printed information were necessary. Zoom
was be used for meetings for CBT-I training with Dr. Haynes, so in person sessions were not
required. This eliminated the need for transportation or extra time allotted for driving and
meeting arrangements. CBT-I training can range between $500-700 depending on the level of the
training program and affiliations. However, basic training for CBT-I and sleep coaching methods
training occurred for free directly from Dr. Patricia Haynes the VA CBT-I provider training
manual.
Data Collection and Outcomes Measurement
Due to the barrier of hectic schedules, firefighters were more likely to drop-out
prematurely due to time constraints and an overwhelming number of surveys or data collection
that demand a timely response. Therefore, creating the simplest survey collection pre- and postintervention may increase participation when working with this population, so a short form
version was selected. The Patient-Reported Outcomes Measurement Information System
(PROMIS) Sleep Disturbance (SD) and the Sleep-Related Impairment (SRI) both measure sleep
quality and sleep-wake function with greater precision than the Pittsburgh Sleep Quality Index
(PSQI) and the Epworth Sleepiness Scale (ESS), which grants an advantage (Yu et al., 2011).

SLEEP DEPRIVATION IN FIREFIGHTERS

23

The PROMIS SD and SRI tool were developed using a rigorous and systematic
methodology, which includes literature reviews, focus groups, review of qualitative items, and
psychometric testing using methods from both item response theory (IRT) and classical test
theory (CTT). The original form banks contain 27 and 16 items each. However, evidence
supports that these question banks may be utilized to create 8-item short forms and are strongly
correlated with similar outcomes as longer forms (Yu et al., 2011). Results from the PROMIS
SD and SRI indicating decreased sleep disruption and increase in quality will determine if
firefighters were able to successfully apply CBT-I coaching and sleep knowledge to improve
their lifestyle.
The CBT Theoretical model will continue throughout the duration of the coaching
sessions by providing the firefighters real time, personalized, feedback regarding their sleep
habits, health concerns, and possible risks vs benefit. This feedback will ideally cue the
firefighter to respond with cues to change behaviors that lead to distress. Whether or not
firefighters experience a cue to action to utilize tools to make change will also be measured
within the screening tools that report the level of sleep disruption.
Firefighters were informed of their right to privacy, and personal identification numbers
will be made for each participant. Personal information was protected, and the survey of
feasibility remained anonymous to the coach. This information was stored on a personal
electronic device which did not contain any identifying data. Additionally, the information stored
was only be kept until the duration of the project had been completed; in which it was the deleted
and disposed of in a proper manner which resonates with the protection of confidential health
information without the ability to trace back. The patient identification number list was shredded
to comply with participant privacy.

SLEEP DEPRIVATION IN FIREFIGHTERS

24

Results
Descriptive Data
There were six firefighters who responded with interest via e-mail through word-ofmouth recruitment on behalf of the fire department union president. Five firefighters completed
the PROMIS SRI and SDA pre-survey, as well as a demographic survey. Two of the five
firefighters responded with a confirmed scheduled date to participate in the sleep coaching intake
session. One firefighter completed the intake, session 1 and 2, and the post-survey. The second
firefighter did not complete session 2 of the sleep coaching intervention but did complete the
post-survey and feasibility measures.
Demographic Data
Summary statistics were calculated for percentages and frequencies of the demographic
data (see Appendix H, Table 1). All project participants were male (n=2, 100%), white race
(n=2, 100%), and both were between the ages of 30-44 (n=2, 100%). Half of the participants
reported 10+ years on the job (n= 2, 50%), and half reported 5-10 years (n=2, 50%).
PROMIS SDA and SRI Data
The average pre-SRI total score (PRESRITS) was 20.5 (SD = 13.44) and the scores
ranged from 11-30 points. The average post-SRI total score (POSTSRITS) was 23 (SD=18.38)
and the scores ranged from 10-36. The average pre-SDA total score (PRESDATS) score was
19.5 (SD=2.12) and the scores ranged from 18-21. The observations for post-SDA total score
(PRESDATS) had an average of 19.00 (SD = 4.24) and the scores ranged from 3-6 (see
Appendix H, Table 2).
Feasibility Measure Data

SLEEP DEPRIVATION IN FIREFIGHTERS

25

In order to assess the feasibility of the intervention, we looked at the following criteria:
how logical sleep coaching seemed, likelihood of continued use, convenience of the phone
method, overall experience, ease of using sleep coaching, how successful sleep coaching was to
alleviating insomnia, if phone use would be recommended for the future, how helpful sleep
coaching was, likelihood of repeating the program, and likelihood of recommending sleep
coaching to other firefighters.
The observations for how logical the program was had an average of 4.00 (SD = 0.00)
and the scores ranged from 0-4. The observations for likelihood of continued use had an average
of 4.00 (SD = 0.00) and the scores ranged from 4-4. The observations for convenience of the
phone method had an average of 4.50 (SD = 0.71) The observations for the overall experience
had an average of 4.50 (SD = 0.71) and the scores ranged from 4-5. The observations for ease of
participation had an average of 3.00 (SD = 2.83 and the scores ranged from 1-5. The
observations for how successful the program was in improving insomnia had an average of 3.00
(SD = 0.00) and the scores ranged from 0-3.
The observations for recommending phone use in the future had an average of 4.50 (SD =
0.71 and the scores ranged from 4-5. The observations for how helpful the program was to
insomnia symptoms had an average of 3.50 (SD = 0.71) and the scores ranged from 3-4. The
observations for willingness to repeat the program had an average of 3.00 (SD = 1.41) and the
scores ranged from 2-4. The observations for likelihood to recommend to another firefighter had
an average of 4.00 (SD = 1.41) and the scores ranged from 3-5 (see Appendix H, Table 3).
Data Analysis
Summary statistics were calculated for pre-SRI total score (PRESRITS), Post-SRI total
score (POSTSDATS), Pre-SDA total score (PRESDATS), and

SLEEP DEPRIVATION IN FIREFIGHTERS

26

Post-SRI total score (POSTSRITS_1) split by years on the job (see Table 4). Summary statistics
were calculated for PRESRITS, POSTSDATS, PRESDATS, and POSTSRITS_1 split by 24hour shift see Table 5). Summary statistics were calculated for PRESRITS, POSTSDATS,
PRESDATS, and POSTSRITS_1 split by age (see Table 6)
Discussion
Clinical significance
Although the statistical significance was inconclusive there was clinical significance. Due
to the relatively small sample size of n=2 and one firefighter who did not complete session 2,
the statistical evidence shows an increase in sleep impairment and disturbance scores. Firefighter
1 was a Male between the ages of 45-49 with 10 years as a firefighter working 24-hour shifts
with no history of sleep disorder or sleep treatment. Background information was obtained, and
the firefighter denied use of nicotine or alcohol, and states caffeine consumption is typically in
the morning. The firefighter stated he was recently ruled out for sleep apnea through
occupational health and did not disclose symptoms of restless leg syndrome. The firefighter
reported that his bed is only used for sleep and sex at night. Firefighter 1 scored a T-score of 51.2
on this pre-SDA and a 38.0 on the pre-SRI, indicating mild sleep disruption and impairment.
Firefighter described his sleep disturbance as unprovoked middle of the night awakenings
without cause, due to light noise, or thinking her heard a service call tone. Firefighter states he
will walk laps around the house to calm himself before returning to sleep. Other times, it takes
him over >40 minutes to fall back asleep if he chooses to stay in bed. Firefighter disclosed
difficulty staying asleep the night before going back on shift, early wakening on days off, and
poor naps when returning home. After completing the intake, and 2 sessions of sleep coaching,

SLEEP DEPRIVATION IN FIREFIGHTERS

27

firefighter reported less middle of the night awakenings, ease of initiating naps, and better quality
of sleep during the night. Reports a post-SDA T-score of 45.5 and a post-SRI T-score of 35.9.
Firefighter 2, a male between the ages of 30-44 with 5-10 years as a firefighter working
24-hour shifts within a busy department, no history of sleep disorder or sleep treatment.
Background information was obtained, and the firefighter discloses use of Nyquil as a sleep aid
when needed and the last year when attending paramedic school. Firefighter states paramedic
school with work demands increased his stress level and sleep became increasingly difficult.
Firefighter denies use of nicotine and less than monthly use of alcohol, and caffeine consumption
in the morning. Reports watching TV in bed with his fiancé at night, but the bedroom is mainly
used for sex and sleep. Firefighter recorded pre-SDA T-score of 47.9 and pre-SRI T-score of
60.4. Firefighter disclosed severe challenges with personal time management and feelings of
anxiety related to incomplete tasks on his to-do list both pre- and post-shift.
Per the documented sleep diary, firefighter recorded an erratic sleep schedule and
bedtime/waketime (on his days off) which fluctuate from the original routine the firefighter
initially disclosed during the intake session. Firefighter 2 was communicative during the
recruitment process and pre-survey but became less engaged withs scheduling a time for an
intake session and session 1. Firefighter rescheduled the session 1 time after missing the
appointment and dropped out before session 2 could be completed (no response after 3 e-mails).
Firefighter disclosed feeling extra stress during the PGA tour (golf tournament) and Barrett
Jackson car show obligations assigned by his station; however, he agreed to finish the postsurvey. The post score for this firefighter increased due to poor time management and an
increase in workload related to special events. The post survey score for was SDA T-score of
52.2 and post SRI T-score of 67.5.

SLEEP DEPRIVATION IN FIREFIGHTERS

28

Limitations
There were several limitations to this intervention. First, time constraints and limited
resources made it challenging to recruit more than 5 participants. The fire department assistant
chief and union president recommended recruitment via word-of-mouth over mass work e-mail
due to concern that too many firefighters would be turned away. A sample size of 2 was
ultimately used out of 6 respondents. However, a larger sample size may have been obtained
with larger recruitment effort. Second, firefighters seemed to respond better via text than work email when scheduling sessions. Using text over e-mail for main communication may increase
retention and participation rates in future research or interventions. Third, questions about
department events, upcoming obligations, change in schedule, and other related personal time
constraints may be important to inquire on prior to the firefighter making commitment to sleep
coaching sessions. Certain life events or added work strain may impact the firefighter’s ability to
fully engage and adjust their sleep routine. Fourth, mental health diagnosis such as anxiety, posttraumatic stress disorder, depression, and other related disorders may be an important factor to
consider when working with a participant with exhibiting insomnia. Although cognitive
behavioral therapy is helpful, it may be more effective in conjunction with medication in certain
circumstances and may depend on the level of impairment to assess severity. Lastly, the
demographic data for age and years on the job was obtained in ranges, instead of an exact
number; making it harder to assess the data.
Sustainability
Funding for fire department programs and activities is either provided through grants or
city funding. Private organizations who choose to work with related stakeholders may consider
additional funding outside of city funding in favor of promoting firefighter wellness. The

SLEEP DEPRIVATION IN FIREFIGHTERS

29

stakeholder in this project Dr. Patricia Haynes, will utilize some feedback information from this
project to enhance future opportunities with other agencies, and tailor the next intervention based
off firefighter feedback in the feasibility survey. This legacy project will continue into a larger
intervention with a greater potential and resources for future sustainability. To continue CBT-I
sleep coaching, the fire department will be required to create a sleep program and hire related
trained professionals to implement these services. Some considerations for funding agencies may
be organizations such as insurance companies and advocacy groups. Ultimately, sleep coaching
wellness promotion and programs may increase firefighter longevity and wellness. Additionally,
they may improve patient and public outcomes, decrease onsite related work-injuries, and
decrease long-term health costs related to preventable illnesses exacerbated by a lack of sleep.

SLEEP DEPRIVATION IN FIREFIGHTERS

30

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SLEEP DEPRIVATION IN FIREFIGHTERS
Appendix A PubMed

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SLEEP DEPRIVATION IN FIREFIGHTERS
Appendix B EBSCO Host

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SLEEP DEPRIVATION IN FIREFIGHTERS
Appendix C ProQuest

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Appendix D PubMed

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Appendix E
Quantitative Evaluation Table

Table 1
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Sullivan, J.P. et al. (2017). Randomized,
Prospective Study of the Impact of a Sleep
Health Program on Firefighter Injury and
Disability.

Behavioral
change
model

Design:
Randomized
field-based
intervention

N=1189
n=601 (EG)
n=588 (CG)

IVIntervention
station:
mandatory
30-minute
education
session on
firefighter
mortality,
fatiguerelated
health
hazards, and
physiological
importance
of sleep.
Voluntary
sleep
screening
posteducation
session.

BQ-SR
AIS
ESTQ

Funding: FEMA, NIOSH, NIH, NLI, and
NBI grants.
Bias: Funders had no role in study design,
data collection or analysis. Authors report no
conflict of interest.
Country: United States

Purpose:
Examine
effectiveness
of sleep
health
program on
firefighter
disability
and injury.

Setting: midsized fire
department in
Columbus, OH
Sample
demographics:
All personnel
from the
selected fire
departments
were instructed
to attend
information
sessions. Mean
age 43.6 years
(EG) 44.4
years (IG).
Female gender
1.3% (EG)
0.8% (IG),
Male Gender
98.2%(EG),
99.2% (IG)

DVFirefighter
sleep quality

Created screening
tool for shiftwork
disorder based on
International
Classification of
Sleep Disorders-2
diagnostic criteria
and referred those
who screened
positive to
American
Academy of Sleep
Medicine
recommended
clinics.

Data
Analysis
(statistics
used)
Chisquare
Fisher’s
exact test
to
compare
gender
and race.
Post hoc
odd ratio
to
calculate
risk of
reported
injuries.
Student’s
t-tests
were used
to
compare
pre and
post
education
session.

Findings/
Results

Level/Quality of
Evidence

Of the 601
firefighters
assigned to
intervention
stations,
90.2%
attended 1
of the 52
educational
sessions.

Strengths:
Sleep disorder
screenings
resulted in 46%
fewer disability
days on
average. Sleep
health program
(SHP) is an
effective way to
increase
knowledge of
sleep health in
firefighters.

DV- only
16% of
firefighters
responded
to end-ofyear study
to report
change in
sleep
quality.
DV2-24%
less likely
to file at
least one
official
injury
report

Weaknesses:
Only 16.2% of
those who
screened
positive sought
medical
treatment and
not beneficial to
long-term
health.
Limitations:
Not RCT
double-blind,

Key: AIS- Athens insomnia scale; BQ-SR-Berlin questionnaire self-report; CG-control group; DV-dependent variable; EGexperimental group; ESTQ-Epidemiology symptoms and Treatment questionnaire; FEMA-Federal Emergency Management Agency;
IV- independent variable; N-number of studies; n- number of participants; NIH-National Institute of Health; NIOSH-National
Institute of Occupational Safety and Health; NHI-National Heart Institute; NLI-National Lung Institute; NBI-National Blood
Institute; SHP- Sleep Health Program.

SLEEP DEPRIVATION IN FIREFIGHTERS

39
Inclusion
Criteria:
All Firefighter
personnel that
work in
Columbus, OH
Fire
Department
were permitted
and encouraged
to attend
informational
session and
join the study.
Exclusion
Criteria: None
listed

DV2firefighter
injuries and
disability
DV3- sleep
disorder
diagnosis or
positive
screening

during the
study
duration
than those
who did not
attend.
DV3-42%
of
firefighters
in this
cohort
screened
positive for
one more
sleep
disorder
compared
to 37%
nationwide

re-assignments
occurred, low
response rate to
end of year
survey.
Bias: may have
occurred due to
low response
rates and
underestimating
the power of the
project.

Key: AIS- Athens insomnia scale; BQ-SR-Berlin questionnaire self-report; CG-control group; DV-dependent variable; EGexperimental group; ESTQ-Epidemiology symptoms and Treatment questionnaire; FEMA-Federal Emergency Management Agency;
IV- independent variable; N-number of studies; n- number of participants; NIH-National Institute of Health; NIOSH-National
Institute of Occupational Safety and Health; NHI-National Heart Institute; NLI-National Lung Institute; NBI-National Blood
Institute; SHP- Sleep Health Program.

SLEEP DEPRIVATION IN FIREFIGHTERS

40

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Barger L.K. et al. (2016).
Implementing a sleep
health education and
sleep disorders screening
program in fire
departments: A
comparison of
methodology.

Behavioral
change
model

Design:
Crosssectional
design

N=2645
n=1002 (EL)
n=892 (TT)
n=751(OL)

Sleep health
program
(SHP) and
screening for
common
sleep
disorders
implemented
in 8 fire
departments
with three
approaches:
1) Expert led,
2) train the
trainer, 3)
online.

Setting: firedepartment with
“off-service”
firefighters or
online at fire
department

IVIntervention
station: 30minute
education
session
delivered with
three different
methodologies.
Including
firefighter
testimonial
videos of sleep
disorder
treatment, and
screening for
common sleep
disorders.

7-point Likert
scale and
questionnaire
based off the
interventional
Classification of
Sleep Disorders-2
(ICSD-2).

Chi-square used
to compare
participation
rates, changes in
assessment
scores,
firefighters’
rating of the
program, and
rate evaluation
and treatment of
sleep disorders.

42% of
firefighters
reported
changing
their sleep
behaviors as
a result from
the program.

Funding: FEMA,
NIOSH, NIH, NIL, and
NIB grants.
Bias: Funders had no role
in study design, data
collection or analysis.
Authors report they were
supported by research
grant through the
Assistance to Firefighters
Grant program. No
conflicts of interest
reported.
Country: United States

Purpose:
Examine and
compare
three
methods of
administering
SHP in fire
departments.

Sample
demographics:
All firefighters
(FF) from the
selected fire
departments
were instructed
to attend
information
sessions.
Total mean age
40.6 years (EL)
42.9 years (TT)
38.0 years, (OL)
40.8 years-Total
Average

DVFirefighter
knowledge of
educational
program
content before
and after the
educational
session.
DV2- Sleep
disorder
diagnosis or

Created screening
tool for sleep
disorder screening
and surveys to
assess level of
knowledge and
SHP impact.

Logistical
regression used
to account for
interdepartmental
variability.

DV- Overall
firefighters
showed
28.6%
knowledge
improvement
rate. FF
DV2-40.8%
of FF
screened
positive for
at least one
sleep
disorder.
DV3- 52.0%
of FF rated
the
importance
of SHP
program.

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths: Fire
Departments were
included with a
phone interview to
determine interest.
Weaknesses:
Challenging to
schedule all
firefighters for
training, had to
include firefighters
on shift but “offduty”. Firefighters
who completed the
OL training were
interrupted to service
calls.
Limitations: Group
viewing of
educational materials
may have impacted
participation rates,
due to lack of
individual postevaluation tools.
Bias: None listed

Key: CG-control group; DV-dependent variable; EG-experimental group; EL- Expert led; FF- Firefighters; FEMA-Federal
Emergency Management Agency; IV- independent variable; N-number of studies; n- number of participants; NIH-National Institute
of Health; NIOSH-National Institute of Occupational Safety and Health; NHI-National Heart Institute; NLI-National Lung Institute;
NBI-National Blood Institute; OL-Online; SHP- Sleep Health Program; TT-Train the Trainer

SLEEP DEPRIVATION IN FIREFIGHTERS
Female gender
(EL) 2.2% (TT)
7.3% (OL) 3.7%
Total 4.3%
Male Gender
(EL) 95.3%
(TT) 89.8%
(OL) 93.9
Total 93.0%

41
positive
screening.
DV3- Program
impact on
firefighters.

Inclusion
Criteria:
All Firefighter
Personnel
working for
selected fire
departments.
Exclusion
Criteria: None
listed

Key: CG-control group; DV-dependent variable; EG-experimental group; EL- Expert led; FF- Firefighters; FEMA-Federal
Emergency Management Agency; IV- independent variable; N-number of studies; n- number of participants; NIH-National Institute
of Health; NIOSH-National Institute of Occupational Safety and Health; NHI-National Heart Institute; NLI-National Lung Institute;
NBI-National Blood Institute; OL-Online; SHP- Sleep Health Program; TT-Train the Trainer

SLEEP DEPRIVATION IN FIREFIGHTERS

42

Citation

Conceptual
Framework

Design/ Method

Sample/
Setting

Major
Variables
studied

Measurement/
Instrumentation

Data
Analysis

Findings

Choi, B., Schnall, P., &
Dobson, M. (2016).
Twenty-four-hour work
shifts, increased job
demands, and elevated
blood pressure in
professional firefighters.

Health Belief
Model

Design:
Cross-Sectional

N=330

IV 1Sedentary
vs.
Strenuous
work
conditions

FORWARD
health
questionnaire to
measure health
and firefighter
specific work.

IV 2number of
shifts/calls
on shifts.

JCQ
ERIQ

ANOVA
and Chisquare used
to example
the whole
sample of
330
firefighters.

DV- Compared to
the standard work
schedule group,
SBP was 3.0 mmHg
(p = 0.20) and 6.6
mmHg (p = 0.10)
higher in the 12–21
shifts and 0–6 shifts
groups, respectively

Funding: Supported by the
CDC and NIOSH
Bias: Authors declare they
have no conflict of interest.
Country: United States

Firefighters used
health
questionnaires to
report working
conditions, and
blood pressure was
clinically assessed
using standard
classification.
Purpose: To
investigate whether
working conditions
(number of 24-hour
shifts, number of
calls, sedentary
work, job strain,
effort-reward
imbalance, and
physical demands)
are associated with
elevated blood
pressure and
hypertension among
professional
firefighters.

Setting: survey
conducted
within health
clinic when FF
visited for
wellness exam.
Sample
demographics:
Professional
firefighters,
321 males,
mean age 42
years; and 9
females, mean
age 37.8 years.
Most
firefighters
were white,
with some
college or high
school
graduate.
Inclusion
Criteria:
Professional
firefighters
who work at

IV 3- Job
strain
DV- SBP &
DBP

Blood pressures
measured by
experienced
nurses with
aneroid
sphygmometer,
twice
consecutively.
Hypertension
defined as
>140mmHg SBP
and >90mmHg
DBP

DBP was also 2.6
mmHg (p = 0.08)
and 4.6 mmHg (p =
0.07) higher in the
12–21 shifts and 0–
6 shifts groups,
respectively.
the two subgroups
(14 shifts and 16
shifts) had
substantially higher
SBP and DBP than
the standard work
schedule group:
4.3–4.4 mmHg (p <

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Strengths: First
Epidemiological
study that
examines
multiple
physical and
psychosocial
working
conditions in
relation to blood
pressure and
hypertension.
Study suggests
limiting the
number of 24hour shifts
firefighters can
work per year to
improve
cardiovascular
health by
limiting
circadian
rhythm
disruption, and
health
promotion
efforts may
impact mild
hypertension.

Key: DBP- diastolic Blood Pressure; DV-dependent variable; FF- Firefighters; FORWARD Study-Explore behavioral and
occupational risk factors for obesity in firefighters; ERIQ-Effort-reward imbalance questionnaire; JCQ-Job content questionnaire;
IV- independent variable; N-number of studies; n- number of participants; SBP- systolic Blood Pressure

SLEEP DEPRIVATION IN FIREFIGHTERS

43
fire stations
and
volunteered to
participate
Exclusion
Criteria:
Rookie
firefighters
with less than
<1 year on the
job; or with
special training
titles (i.e.
medical
director,
training officer,
investigator);
or who did not
have valid
information on
the other study
variables in
current study.
Anyone taking
current
hypertensive
medications
were excluded
from the
multivariate
model.

0.20) for SBP and
3.4–5.0 mm Hg (p <
0.05) for DBP

Weaknesses:
Cross-sectional
study, unable to
be sure of
temporal
relationships of
the number of
24-hour shifts
in the past
month and
increased job
demand over
the past years.
Limitations:
Self-reporting
information
may need test
and retest over
long term.
Study was
unable to assess
whether noise
exposure may
impact SBP and
DBP (i.e.,
Sirens)
Bias: No bias
reported.

Key: DBP- diastolic Blood Pressure; DV-dependent variable; FF- Firefighters; FORWARD Study-Explore behavioral and
occupational risk factors for obesity in firefighters; ERIQ-Effort-reward imbalance questionnaire; JCQ-Job content questionnaire;
IV- independent variable; N-number of studies; n- number of participants; SBP- systolic Blood Pressure

SLEEP DEPRIVATION IN FIREFIGHTERS

44

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Billings, Joel & Focht, Will. (2016). Firefighter
shift schedules affect sleep quality.

Parallel
multiple
mediator
model

Design:
Crosssectional
design

N=109
n= (24/48)31
n= (48/96)38
n=(Kelly)40

PSQI

STATA
software
used to
analyze data

Sleep quality
was assessed
using a
Pittsburgh
Sleep
Quality
Index in a
sample of
109 male
career
firefighters
from six fire
departments
in three
Southwestern
US states and
26 different
stations.

Setting: 26
different firedepartments

IV 1-Shift
schedule
worked;
24on/48off,
48on/96off,
or Kelly.

DV 1- Based
on a sample
of 109
firefighters
from the six
fire
departments,
80 of the
109 (73%)
firefighters
report poor
sleep quality
with a PSQI
score of >5.

Funding: No funding listed
Bias: No bias reported
Country: United States

Purpose:
investigate
the
prevalence
and severity

Sample
demographics:
All respondents
are male, and
most are
married, have
children living
at home, work
a second job,
and worked in
the fire service
an average of
nearly 13
years.

IV 2- Second
jobs
DV 1- Sleep
quality
DV 2Dysrhythmia

DV 2Differences
in sleep
quality
between
Kelly and
the other
two shift
schedules
show that
the greater

Level/Quality of
Evidence;
Decision for
practice/
application to
practice
Strengths:
Current only
peer-reviewed
literature that
explores
firefighters
working second
jobs, and the
impact on sleep.
Shift schedules
that disrupt
normal
circadian
rhythms more
result in poorer
sleep quality,
which can lead
to less effective
emergency
response and
increased risk to
firefighter
health and
safety.
Weaknesses:
none listed
Limitations:
none listed

Key: 24/48-24-hours on-duty and 48-hours off; 48/96- 48-hours on-duty and 96-hours off; DV-dependent variable; FF- Firefighters;
IV- independent variable; Kelly-24-hours on-duty, 24-hours off, 24-hours on-duty, 24-hours off, 24-hours on-duty, 96 hours off; Nnumber of studies; n- number of participants; PSQI-Pittsburg sleep quality index

SLEEP DEPRIVATION IN FIREFIGHTERS
of firefighter
sleep quality
across
department
shift
schedules

45
Inclusion
Criteria:
Only full-time
firefighters
with at least
one month of
current
continuous
shift-work
experience
were recruited
to participate in
interviews held
at their fire
stations.
Exclusion
Criteria: None
listed

the
dysrhythmia,
the poorer
the sleep
quality.

Bias: none
listed

70 of the
109 (64%)
of
firefighters
work in jobs
outside of
the fire
department.
The results
suggest that
working
second jobs
during time
off between
work shifts
may further
adversely
affect sleep
quality

Key: 24/48-24-hours on-duty and 48-hours off; 48/96- 48-hours on-duty and 96-hours off; DV-dependent variable; FF- Firefighters;
IV- independent variable; Kelly-24-hours on-duty, 24-hours off, 24-hours on-duty, 24-hours off, 24-hours on-duty, 96 hours off; Nnumber of studies; n- number of participants; PSQI-Pittsburg sleep quality index

SLEEP DEPRIVATION IN FIREFIGHTERS

46

Citation

Theory/
Conceptual
Framewor
k

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats used)

Findings/
Results

Smith, L.J., Bartlett, B.A., Tran, J.K. et al.
Sleep disturbance among firefighters:
understanding associations with alcohol use
and distress tolerance.

crosssectional
design

DesignSecondary
analysis of
data from a
larger project
examining
stress and
health-related
behaviors
among
firefighters

N=652
Firefighters

Bivariate
correlations
IV 1: Alcohol
Use

Hierarchical
regression
analysis was
conducted

Descriptive
statistics.

Setting: All
firefighters
were
recruited for
participation
in an online,
survey-based
study through
a large urban
fire
department in
the southern
United States.

AUDIT
DTS
PSQI
SOOS-14

Funding: Study was unfunded
Bias: No bias reported
Country: United States

Purpose-To
focus on
better
understandin
g relations
among
alcohol use,
distress
tolerance, and
sleep
disturbances
among
firefighters

Sample
demographic
s:
Male:611
Female: 36
Transgender:
5 Mean age:
38.4
Inclusion
Criteria:
18 years of
age or older,
been a current
firefighter,
and consented

IV 2: Stress
tolerance
DV 1: Sleep
Efficiency

Bivariate
correlations.
IV 1: Alcohol
use increased
with sleep
disruption and
poor distress
tolerance.
IV 2: Sleep
efficiency was
significantly
and negatively
correlated
with poor
stress
tolerance.
DV 1:
Alcohol use
severity was
significantly
associated
with sleep
disturbance,
sleep
efficiency,

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths:
The current
literature examined
a large sample from
a unique population
that is highly
understudied
regarding substance
use and health
behaviors.
Study was unfunded
Interventions to
improve sleep
quality
among firefighters
may include
programs include
discussion of the
health impact of
sleep disturbance,
education regarding
associations
between alcohol use
and sleep
disturbance, an
emphasis on
building distress
tolerance skills to
enhance emotional
coping and thus
improve sleep

Key: AUDIT- alcohol use identifications test; DTS-distress tolerance scale; DV-dependent variable; FF- Firefighters; IVindependent variable; N-number of studies; n- number of participants; PSQI-Pittsburgh sleep quality index; SOOS-14-sources of
occupational stress

SLEEP DEPRIVATION IN FIREFIGHTERS

47
to
participation
and
completion of
all online
questionnaire
s.
Furthermore,
reported
drinking
alcohol on at
least a
“monthly or
less” basis,
which used to
measure
alcohol use.
Exclusion
Criteria:
Unwilling to
provide
informed
consent for
the
completion of
the online
questionnaire,
or those who
did not wish
to participate.

perceived
sleep quality,
and daily
disturbances.
Years of
service within
the fire
department
was not
significantly
correlated
with sleep
quality,
alcohol use or
distress
tolerance.

quality and reduce
alcohol use, and
screening (and
appropriate
referrals) for
problematic alcohol
use.
Weaknesses:
Cross sectional
study
Limitations:
Possible under
reporting due to job
loss concerns among
career firefighters
Bias: none listed

Hierarchical
regression
analysis was
conducted
Post-hoc
exploratory
analyses

Key: AUDIT- alcohol use identifications test; DTS-distress tolerance scale; DV-dependent variable; FF- Firefighters; IVindependent variable; N-number of studies; n- number of participants; PSQI-Pittsburgh sleep quality index; SOOS-14-sources of
occupational stress

SLEEP DEPRIVATION IN FIREFIGHTERS

48

Citation

Theory/
Conceptual
Framewor
k

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measure
ment/
Instrumen
tation

Data
Analysis
(stats used)

Findings/
Results

Serrano, D.M., et al. (2020). Association
between sleep disturbances and suicide risk
among firefighters: the moderating role of
mindfulness.

crosssectional
design

DesignCrosssectional
design

N=865
Firefighters

IV 1:
Mindfulness

Setting: The
fire
department
has an
online
continuing
education
portal where
the
participants
were able to
access the
study and
relevant
documents if
they chose
to participate

DV 1: Sleep
Disturbance

LEC-5
IDAS
SBQ-R
FFMQ
PSQI
SOOS-14

Descriptive
statistics
and
bivariate
correlations
among
main
variables.

DV-1: Suicide risk
was statistically
significantly and
positively associated
with occupational
stress (r = .35, p <
.001), life- time
trauma load (r = .16,
p < .001), depression
and anxiety
symptoms (r = .32, p
< .001), and sleep
disturbance (r = .36,
p < .001).

Funding: None specified
Bias: Authors declare they have no conflict
of interest.
Country: United States

Secondary
analysis of
data from a
larger project
examining
stress and
health-related
behaviors
among
firefighters
Purpose-To
focus on
better
understandin
g relations
among
alcohol use,
distress
tolerance, and
sleep
disturbances
among
firefighters

Sample
demographi
cs:
Male:813
Female:46
Transgender
:6

DV 2: Suicide
Risk

DV 2: Suicide risk
was also statistically
significantly but
negatively associated
with overall
mindfulness (r = −
.13, p < .001), the
awareness
mindfulness facet (r =
− .28, p < .001), and
the nonjudgmental
mindfulness facet (r =
− .31, p < .001),
whereas the nonreactivity (r = .09, p <
.01) and the
observing facets (r =

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths:
Mindfulness is a
promising
intervention for
improving mental
health in
firefighters.
Weaknesses:
Cross sectional
study
Limitations:
Majority of
firefighters are
white male, future
studies should
include
transgender, and
minorities.
Assessment of
prior level of
experience in
mindfulness or
meditation was not
measured.
Bias: Potential bias
since study relied
on self-reporting
measures. Other
barriers could not
be ruled out.

Key: AUDIT- alcohol use identifications test; DTS-distress tolerance scale; DV-dependent variable; FF- firefighters; FFMQ-five
facet of mindfulness questionnaire; IDAS- inventory of depression and anxiety symptoms; IV- independent variable; LEC-5life events checklist for DSM 5; N-number of studies; n- number of participants; PSQI-Pittsburgh sleep quality index; SOOS14-sources of occupational stress

SLEEP DEPRIVATION IN FIREFIGHTERS

49
Mean age:
38.50
Inclusion
Criteria:
All and any
firefighters
from the
selected fire
department.

.20, p < .001) were
positively associated
with suicide risk.

Exclusion
Criteria:
None listed

Key: AUDIT- alcohol use identifications test; DTS-distress tolerance scale; DV-dependent variable; FF- firefighters; FFMQ-five
facet of mindfulness questionnaire; IDAS- inventory of depression and anxiety symptoms; IV- independent variable; LEC-5life events checklist for DSM 5; N-number of studies; n- number of participants; PSQI-Pittsburgh sleep quality index; SOOS14-sources of occupational stress

SLEEP DEPRIVATION IN FIREFIGHTERS

50

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats used)

Findings/
Results

Lim M., et al. (2020). Psychosocial
factors affecting sleep quality of preemployed firefighters: a cross-sectional
study.

Cross-sectional
design

DesignCrosssectional
design

N=602
Firefighters

IV:
Psychosocial
factors

PHQ-9

DV: Sleep
Quality

ISI

Independent
2 sample ttest to
examine
relationship
between
general
characteristi
c,
psychologic
al factors,
social
support, and
sleep
quality.

Sleep quality
of preemployed
firefighters
are like
civilians than
on-duty
firefighters.

Funding: Supported by the Field
oriented Support of Fire Fighting
Technology Research and Development
Program funded by National Fire
Agency
Bias: Authors declare they have no
conflict of interest.
Country: Korea.

Brief lecture
about sleep,
followed by a
self-report
questionnaire
survey.
Purpose-To
focus on
sleep quality
of preemployed
firefighters,
and to
examine
sleep quality
and
psychosocial
factors.

Setting:
Fire
academy
Sample
demograp
hics:
Male:480
Female:122
Mean age:
97.3% of
sample
between
20-30 years
old
Inclusion
Criteria:
Firefighters
who
completed
a 15-week
academy,
required
training
course, and
had passed

GAD-7

FSSQ
PSQI

Logistic
regression
was used to
evaluate
effects of
psychosocia
l factors on
sleep
quality

Sleep
disturbances
were
correlated
with different
circadian
rhythms.
Sleep is
significantly
correlated
with
psychological
factors
Higher social
support
correlated
with higher
quality sleep.

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths: First
study to examine
pre-employed
firefighters.
Included many
psychosocial factors
that may be useful
for identifying
patterns.
Weaknesses:
Cross sectional
study
Limitations:
Presence of a child,
child-care activities
and history of sleep
medication was not
addressed. Only 1%
of total subjects in
the study reported
taking a sleeping
pill.
Bias: Bias and nonbias responses on
self-reporting
questionnaires
cannot be ruled out.

Key: DBP- diastolic blood pressure; DV-dependent variable; GAD-7-generalized anxiety disorder 7;FF- Firefighters; FSSQfunctional social support questionnaire; ISI-Insomnia severity index; IV- independent variable; N-number of studies; n- number of
participants; PSQI-Pittsburgh sleep quality index; SBP- systolic blood pressure

SLEEP DEPRIVATION IN FIREFIGHTERS

51
the fire
officer test.
Exclusion
Criteria:
349 people
did not
respond to
any of the
survey
questions.

Key: DBP- diastolic blood pressure; DV-dependent variable; GAD-7-generalized anxiety disorder 7;FF- Firefighters; FSSQfunctional social support questionnaire; ISI-Insomnia severity index; IV- independent variable; N-number of studies; n- number of
participants; PSQI-Pittsburgh sleep quality index; SBP- systolic blood pressure

SLEEP DEPRIVATION IN FIREFIGHTERS

52

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats used)

Findings/
Results

Nakada, Y., Sigumoto, A., Kadotani, H.,
& Yamada, N. (2018). Verification of
effect of sleep health education program
in workplace: a quasi-randomized
controlled trial.

Quasirandomized
control trial

Design- Study
divided into two
groups,
intervention, and
control group.
Sleep health
education was
provided to both
subjects and
employees for
primary
prevention in the
workplace.

N= 77
Firefighters

IV 1: Sleep
Health
Program (SHP)

ESS

DV 1:
Effectiveness
of education

PHQ-9

ANOVAUsed to
assess the
changes by
intervention
in the two
groups

Weekday
sleep duration
increased
significantly
among the
intervention
group who
used MTN210 compared
to the control
group.

Funding: None listed
Bias: Authors declare they have no
conflict of interest.
Country: Japan

Purpose- test the
effectiveness of
sleep health
education in the
workplace for
about half a year
in terms of
primary
prevention of
mental health
and then to
investigate sleep
changes both
subjectively and
objectively using

Setting:
Workplace
setting
Sample
demograp
hics:
Male:42
Female:28
Mean age:
43.1
Inclusion
Criteria:
Employees
within a
pharmaceut
ical
company
Exclusion
Criteria:
341 of 418
who denied

AIS

SF-8
MTN-210

t-tests used
between the
two groups
for group
comparison
Category
data
measured
with X2
test,
McNemar
test, and
Fisher’s
Exact.

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths: Q-QCT
study results
indicate a significant
increase in the
weekday sleep
duration in the
intervention group
using a sleep health
educational
program. Included
16 shift workers.
Weaknesses: Small
sample size
Limitations: Used
employee numbers
to randomize instead
of traditional means.
Subjects could be
health-minded since
it was conducted at
a pharmaceutical
site.
Bias: Bias and nonbias responses on
self-reporting
questionnaires
cannot be ruled out.

Key: AIS-Athens insomnia scale; AUDIT- alcohol use disorders identification Test; DV-dependent variable; ESS-Epworth
sleepiness scale; FF- Firefighters; IV- independent variable; KOSS-SF- Korean occupational stress scale; PHQ-9- patient health
questionnaire; MTN-210-Self-administered questionnaires and activity monitor; N-number of studies; n- number of participants; SF8- health-related QOL score-standard version

SLEEP DEPRIVATION IN FIREFIGHTERS
selfadministered
questionnaires
and activity
monitor

53
inclusion of
the study.

Key: AIS-Athens insomnia scale; AUDIT- alcohol use disorders identification Test; DV-dependent variable; ESS-Epworth
sleepiness scale; FF- Firefighters; IV- independent variable; KOSS-SF- Korean occupational stress scale; PHQ-9- patient health
questionnaire; MTN-210-Self-administered questionnaires and activity monitor; N-number of studies; n- number of participants; SF8- health-related QOL score-standard version

SLEEP DEPRIVATION IN FIREFIGHTERS

54

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major
Variables &
Definitions

Won, G. et al. (2020). The effect of a mental
health promotion program on Korean
firefighters.

CrossSectional

Design- 2year program
of mental
health
promotion:
consisted of
60-minute
general
education,
one 30minute
individualize
d counseling
session, and
four 30minute
counseling
sessions for
those deemed
high risk, and
BIC

N= 1,859
Firefighters

IV 1:
Mental
Assessment
and
Promotion
Health
Program

PurposeAssess
firefighter
mental health
and provide
individualize
d support to
local

Exclusion: None
listed

Funding: Authors received funding from
NFARK
Bias: Authors declare they have no conflict of
interest.
Country: Korea

Setting:
“Counseling
Center for
Firefighters”
Sample
demographics:
Male:1,757
Female: 97
Mean age: 40.75
Inclusion
Criteria:
All firefighters
who received
notice of the
study.

Criteria: Any
active firefighter
who visited the
“Visiting
Counseling

DV 1:
Mental
Health

Measureme
nt/
Instrumentat
ion
PCL
BDI
BAI
BSS
ISI
AUDIT-K
WHOQOLBREF

Data
Analysis
(stats
used)
Paired
sample ttests for
parametric
data or
Wilcoxon
for nonparametric
data.
Independe
nt t-tests
or the
MannWhitney
test to
compare
clinical
characteris
tic.
Qualitativ
e variables
including
sociodemo
graphic
data
compared

Findings/
Results
IV-Participants
showed
psychopatholog
ical
improvement
throughout the
2 years.
The PCL
(p=.001), BDI
(p =.000), BAI
(p =.000), BSS
(p =.000), ISI (p
=.000) and
AUDIT-K (p
=.000) scores
all significantly
improved.

Level/Quality of
Evidence; Decision for
practice/ application to
practice
Strengths: Large
sample size, low
selection bias due to
systemic approach.
Offered participants an
opportunity for
introspection and
detect those in need of
aid.
Weaknesses:
Only recruited
participants from a
Geyongsang-do
providence in Korea
Limitations: all
changes were
compared before and
after the program
without follow-up, and
mental health
assessments are selfadministered so bias
cannot be ruled out.
Bias: Bias and nonbias responses on selfreporting
questionnaires cannot
be ruled out.

Key: AUDIT-K-Alcohol use disorder identification test-Korea; BAI- Beck’s anxiety inventory; BIC-Brief intensive counseling; BDIBeck’s depression inventory; BSS- Beck scale for suicidal ideation; DV-dependent variable; ISI-Insomnia severity index; IVindependent variable; N-number of studies; NFARK-National Fire Agency Republic of Korea; n- number of participants; PCL-Posttraumatic checklist; PSQI-Pittsburgh sleep quality index; WHOQOL-BREF-World health organization quality of life

SLEEP DEPRIVATION IN FIREFIGHTERS
firefighters
through a
mental health
promotion
program.

55
Center for
Firefighters”

using chisquare
test,
Fisher’s
exact test
and linear
by linear
associatio
n.

Key: AUDIT-K-Alcohol use disorder identification test-Korea; BAI- Beck’s anxiety inventory; BIC-Brief intensive counseling; BDIBeck’s depression inventory; BSS- Beck scale for suicidal ideation; DV-dependent variable; ISI-Insomnia severity index; IVindependent variable; N-number of studies; NFARK-National Fire Agency Republic of Korea; n- number of participants; PCL-Posttraumatic checklist; PSQI-Pittsburgh sleep quality index; WHOQOL-BREF-World health organization quality of life

SLEEP DEPRIVATION IN FIREFIGHTERS

56

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats used)

Findings/
Results

Smith, E., Velazquez-Pimentel, D., &
Trockels, A. (2019). Posttraumatic
Stress Disorder and Sleep Quality
Among Urban Firefighters In Thailand.

Cross-sectional
design

DesignCrosssectional

N=1215
Firefighters

IV 1: PTSD
severity using
PLC-C
assessment

PCL-C-THAI

SPSS

PSQI-THAI

Bivariate
analysis
used Chisquare

Of the 1215
firefighters,
78 were
categorized
into PTSD
group using
PCL-C scores.

Funding: 90th Anniversary of
Chulalongkorn
Nature and Science of Sleep 2019:11
University Fund, Office of Higher
Education Commission and TRF.
Bias: Authors declare they have no
conflict of interest.
Country: Thailand

Analysis of
35 fire
stations to
determine
effects of
trauma on
sleep quality.
Purpose- To
find an
association
between
PTSD and
sleep quality
among
firefighters.

Setting: 35
Fire stations
under Fire
Brigade
Division of
Bangkok
Metropolitan
Administrati
on.
Sample
demographi
cs:
Male:1215
Mean age:
39 years
Inclusion
Criteria:
actively
working as a
firefighter
for at least
one year,
age more
than or equal
18 years old

DV 1: Sleep
Quality

Fisher’s
exact test
used if
assumption
was not met
Continuous
data sample
t-tests were
applied.
If data was
skewed,
MannWhitney U
test was
used.

88.5% of
firefighters
with PTSD
reported poor
sleep quality,
compared to
46.4%
without
PTSD.

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths:
Significant
association between
PTSD and sleep
quality among
firefighters. Current
study suggests
interventions and a
policy related to
psychological wellbeing among
firefighters may
enhance health.
Limitations: Sleep
quality was not
differentiated for
on-duty and off-duty
it was within a 30day timeframe.
Call volumes were
not considered.
Cross-sectional
studies cannot
conclude the
relationship between
PTSD and sleep.
Study cannot be
generalized for
wildfire firefighters.
Different cut off

Key: DV-dependent variable; FF- Firefighters; IV- independent variable; N-number of studies; n- number of participants; PLC-Cposttraumatic stress disorder checklist-civilian version; PTSD-posttraumatic stress disorder; PSQI-THAI-pittsburgh sleep quality
index; TRF-Thailand research fund

SLEEP DEPRIVATION IN FIREFIGHTERS

57
and male
firefighters.
Exclusion
Criteria:
None listed

point for
questionnaire.
Bias: Bias cannot be
ruled out in selfreporting surveys.

Key: DV-dependent variable; FF- Firefighters; IV- independent variable; N-number of studies; n- number of participants; PLC-Cposttraumatic stress disorder checklist-civilian version; PTSD-posttraumatic stress disorder; PSQI-THAI-pittsburgh sleep quality
index; TRF-Thailand research fund

SLEEP DEPRIVATION IN FIREFIGHTERS

Citation

Kim, J., Park, H., & Kim, J. (2018). Alcohol
use disorders and insomnia mediate the
association between PTSD symptoms and
suicidal ideation in Korean firefighters.
Funding: None specified
Bias: Authors declare they have no conflict
of interest.
Country: South Korea

Theory/
Conceptu
al
Framewo
rk
Crosssectional
design

58

Design/ Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

DesignCross sectional

N=7190
Firefighters

IV 1: Alcohol
Use

AUDITKOREA

Part of a selfreport online
survey
administered in
34 fire-stations

Setting: 34
fire stations
in South
Korea, two
headquarters
and one
academy.

IV 2: Insomnia

AIS-KOREA

DV 1: PTSD

PCL-KOREA

DV 2: Suicidal
Ideation

PHQ-9KOREA

Hierarchical
multivariable
linear
regression
analyses were
performed to
identify the
relationship
of AUDs and
insomnia with
suicidal
ideation.

DV 1-377
Firefighters
were found
to have
probable
PTSD in the
past month.

PurposeInvestigate the
mediating role of
AUDs (Alcohol
use disorders)
and insomnia in
the relationship
between PTSD
(Posttraumatic
stress disorder)
symptoms and SI
(suicidal
ideation).

Sample
demographi
cs:
Male: 6,521
Female:669
Mean age:
39.6 years
old
Average
years of
work:12.5
years
Inclusion
Criteria:
All and any
firefighters
from the

DV 2-PTSD
symptoms
showed
positive
association
with suicidal
ideation, and
the number
of traumatic
events were
significantly
associated
with suicidal
ideation
The indirect
effect of
PTSD
symptoms
on suicidal
ideation was
mediated by
AUDs and

Level/Quality of
Evidence; Decision
for practice/
application to
practice
Strengths: First
study to investigate
the role of AUDs
and insomnia in the
relationship between
PTSD symptoms
and suicidal
ideation. Hypothesis
can be made that
after exposure to
trauma, PTSD
symptoms occur,
leading to increased
use of alcohol which
increased insomnia
and leads to sleep
disturbances;
ultimately leading to
suicidal ideation.
Weaknesses:
Cross sectional
study
Limitations:
Majority of
firefighters are
Korean male.
Firefighters may
underreport suicidal
ideation or PTSD
symptoms due to
stigma of being

Key: AIS-Athens insomnia scale; AUD-Alcohol Use Disorder; AUDIT-Alcohol use disorder identification test; DV-dependent
variable; FF- Firefighters; IV- independent variable; N-number of studies; n- number of participants; PCL-PTSD symptom checklist;
PHQ-9-Patient health questionnaire; PTSD-posttraumatic stress disorder; SI-suicidal ideation

SLEEP DEPRIVATION IN FIREFIGHTERS

59
selected fire
department.
Exclusion
Criteria:
None listed

insomnia,
PTSD
symptoms
were
significantly
associated
with AUDs
(𝛽𝛽 = 0.165,
P < 0.001),
AUDs were
significantly
associated
with
insomnia (𝛽𝛽
= 0.150, P <
0.001), and
insomnia
was
significantly
associated
with suicidal
ideation (𝛽𝛽
= 0.018, P <
0.001).

“weak” or
“vulnerable”. Did
not obtain
information on plan
or actual attempt of
suicide. Limited to
Korean firefighters
in one province.
Socioeconomic
status factors were
not considered.
Bias: Potential bias
since study relied on
self-reporting
measures.

Key: AIS-Athens insomnia scale; AUD-Alcohol Use Disorder; AUDIT-Alcohol use disorder identification test; DV-dependent
variable; FF- Firefighters; IV- independent variable; N-number of studies; n- number of participants; PCL-PTSD symptom checklist;
PHQ-9-Patient health questionnaire; PTSD-posttraumatic stress disorder; SI-suicidal ideation

SLEEP DEPRIVATION IN FIREFIGHTERS

60
Appendix F

Table 2
Synthesis Table
Author
Year
Design/Level of
Evidence:
Demographics
Age (Mean y.o.)
Males %
Female %
Unknown/Transgender
Setting:
On-site Workplace
Fire Academy
Off-Site Clinic
Sample Size/ # of
Studies Included
Measurement Tools

Sullivan
2017
RCT/II

Barger
2016
CS/V

Choi
2016
CS/V

Billings
2016
CS/V

Smith
2017
CS/V

Serrano
2020
CS/V

Lim
2020
CS/V

Won
2020
CS/V

Nakada
2018
QRCT/III

Smith
2019
CS/V

58.4
100
40
60

20-30
79.7
20.3
n/a

40.75
89
11
n/a

40-49
60
40
n/a

64.6
73
46
39.8

Study Characteristics
43.6
98.7
1.3

X

40.8
95.3
2.2
2.5

55-64
61.1
44.4
50
X

1189

2645

AIS, BQSR,
ESTQ

LS, ICSD-2

X
330
JCQ
ERIQ

60
80
n/a
n/a

52.5
85.3
29.4
61.8
X

X

X

103

53

37 (NRNCT),
18 (DQ)
LEC-5
IDAS
SBQ-R
FFMQ
PSQI
SOOS-14

PSQI

AUDIT
DTS
PSQI
SOOS-14

X
602
PHQ-9
GAD-7
ISI
FSSQ
PSQI

X
1859
PCL
BDI
BAI
BSS
ISI
AUDIT-K
WHOQOLBREF

X

X

77

1215

ESS
AIS
PHQ-9
SF-8
MTN-210

PCL-CTHAI
PSQI-THAI

Key: AIS- Athens insomnia scale; BDI - Beck’s depression inventory; BQ-SR – Berlin questionnaire self-report; CS-cross-sectional; CG - control group; DVdependent variables; EG – experimental group; ERIQ- effort-reward imbalance questionnaire; ESTQ-epidemiology symptoms and treatment questionnaire;
FSSQ-functional social support questionnaire GAD-7-generalized anxiety disorder screen; ICSD-2 – classification of sleep disorders-2; ISI-insomnia severity
index; JCQ-job content questionnaire; IV- independent variables; LS – Likert Scale; MHPP-mental health promotion program; m – months; n/a – not
applicable; PHQ-9 - patient health questionnaire -9; PSQI-Pittsburgh sleep quality index RCT – randomized control trial; QRCT-quasi-randomized control
trial; SHP – sleep health program; sx-symptoms; WHOQOL-BREF – world health quality of life measure brief; y/o-years old; * - statistically significant with
p-value ≤ 0.050;  - increased;  - decreased;

SLEEP DEPRIVATION IN FIREFIGHTERS

Duration of
Intervention
(minutes)
Blood Pressure
Measurement
Expert Led SHP
MHPP
Mindfulness
Online Module SHP
Train-The-Teacher SHP
SHP
SHP Policy
Screening Tools
Anxiety
Health Knowledge
Hypertension
Injury/Disability
Psychopathological sx
PTSS
Sleep Deprivation
Sleep Knowledge
Suicidality

30

30

61

6

20

60

60

n/a

X
X
X
X

X

n/a

X

X

X
X

X

X








150

IV – Interventions

X

X

90-160

X
X
DV-Dependent Variable


X

X

X

X










X





















Key: AIS- Athens insomnia scale; BDI - Beck’s depression inventory; BQ-SR – Berlin questionnaire self-report; CS-cross-sectional; CG - control group; DVdependent variables; EG – experimental group; ERIQ- effort-reward imbalance questionnaire; ESTQ-epidemiology symptoms and treatment questionnaire;
FSSQ-functional social support questionnaire GAD-7-generalized anxiety disorder screen; ICSD-2 – classification of sleep disorders-2; ISI-insomnia severity
index; JCQ-job content questionnaire; IV- independent variables; LS – Likert Scale; MHPP-mental health promotion program; m – months; n/a – not
applicable; PHQ-9 - patient health questionnaire -9; PSQI-Pittsburgh sleep quality index RCT – randomized control trial; QRCT-quasi-randomized control
trial; SHP – sleep health program; sx-symptoms; WHOQOL-BREF – world health quality of life measure brief; y/o-years old; * - statistically significant with
p-value ≤ 0.050;  - increased;  - decreased;

SLEEP DEPRIVATION IN FIREFIGHTERS
Appendix G
Models and Frameworks
Figure 1
The Cognitive Behavioral Therapy Model

62

SLEEP DEPRIVATION IN FIREFIGHTERS

Figure 2
A Knowledge to Action Framework

63

SLEEP DEPRIVATION IN FIREFIGHTERS

64

Appendix H
Table 1
Demographics (n=2)
Variable

%

Race
white

100

Age
45-49

50

30-44

50

Years_on_Job
10+

50

5-10

50

Gender
male

100

X24_hour_shift
yes

100

sleep_dx_or_tx
no

100

Table 2
Sleep Related Impairment and Sleep Disturbance Assessment Descriptive Statistics (n=2)
M

SD

Min

Max

PRE-SRI Total Score
POST-SRI Total Score

20.50
23.00

13.44
18.38

11.00
10.00

30.00
36.00

POST-SDA Total Score
PRE-SDA Total Score

19.00
19.50

4.24
2.12

16.00
18.00

22.00
21.00

Variables

SLEEP DEPRIVATION IN FIREFIGHTERS

65

Table 3
Feasibility Measure (n=2)

M
4.00
4.00
4.50
4.50
3.00
3.00
4.50
3.50
3.00
4.00

Variables

LOGICAL1
CONTINUED_USE4
CONVENIENCE_OF_PHONE7
OVERALL_EXPERIENCE10
EASE2
SUCCESSFUL5
RECOMMEND_PHONE8
HELPFUL3
REPEAT_PROGRAM6
RECOMMEND_TO_FIREFIGHTERS9

SD
0.00
0.00
0.71
0.71
2.83
0.00
0.71
0.71
1.41
1.41

Min
4.00
4.00
4.00
4.00
1.00
3.00
4.00
3.00
2.00
3.00

Max
4.00
4.00
5.00
5.00
5.00
3.00
5.00
4.00
4.00
5.00

Table 4
Summary Statistics Table for Interval and Ratio Variables by Years_on_Job (n=2)
Variable
PRESRITS
10+
5-10
POSTSDATS
10+
5-10
PRESDATS
10+
5-10
POSTSRITS_1
10+
5-10

M

SD

Min

Max

11.00
30.00

-

11.00
30.00

11.00
30.00

16.00
22.00

-

16.00
22.00

16.00
22.00

21.00
18.00

-

21.00
18.00

21.00
18.00

10.00
36.00

-

10.00
36.00

10.00
36.00

SLEEP DEPRIVATION IN FIREFIGHTERS

66

Table 5
Summary Statistics Table for Interval and Ratio Variables by X24_hour_shift (n=2)
Variable

M

SD

Min

Max

20.50

13.44

11.00

30.00

19.00

4.24

16.00

22.00

19.50

2.12

18.00

21.00

23.00

18.38

10.00

36.00

PRE-SRI Total Score
Yes 24-hour shift
POST-SDA Total Score
Yes 24-hour shift
PRE-SDA Total Score
Yes 24-hour shift
POST-SRI Total Score
Yes 24-hour shift

Table 6
Summary Statistics Table for Interval and Ratio Variables by Age (n=2)
Variable

M

SD

Min

Max

45-49

11.00

-

11.00

11.00

30-44

30.00

-

30.00

30.00

45-49

16.00

-

16.00

16.00

30-44

22.00

-

22.00

22.00

45-49

21.00

-

21.00

21.00

30-44

18.00

-

18.00

18.00

45-49

10.00

-

10.00

10.00

30-44

36.00

-

36.00

36.00

PRESRITS

POSTSDATS

PRESDATS

POSTSRITS_1