6 steps to change: Influencing firefighters’ perceptions of PPE use and care
How a new communications-focused approach helped one department’s members adopt improved PPE decontamination behavior
In “Firefighter PPE compliance: How to achieve buy-in,” I wrote about how a systematic approach that creates a “new normal” within the department is critical to firefighter commitment when it comes to keeping PPE clean to reduce the risk from toxic chemicals, chemical compounds and carcinogens found in today’s structure fires. But there’s more to that process than meets the eye, and that’s what I’m going discuss in this article: how to create a new normal in your fire department regarding PPE decontamination and other mitigation measures after a fire.
In the study “The Invisible Danger of Bunker Gear Transfer,” the researchers affirm that after exposure to the toxic mix of chemicals, chemical compounds and carcinogens present in today’s structure fires, firefighters can absorb them through skin contact or inhale them as they off-gas. Further, the industry’s increased awareness of these risks has caused fire department leaders to create policies and practices focused on gear cleaning and decontamination processes to decrease risk; however, such efforts are in their infancy in many departments and tend to be somewhat piecemeal in nature.
This second point is of particular note, as this has been the fire service “standard” approach to any problem: We become aware of the problem; figure out why it’s a problem; develop a training program to make everyone aware of the problem; write a policy or procedure to tell everyone how to avoid the problem. The end.
But this isn’t having the desired impact. We see the videos of fireground operations and know fellow members who continue to take unsafe actions, compromising their health and safety.
Our history provides perspective on resistance
I believe part of the reason some firefighters may resist tackling this health threat head on comes down to the fact that we don’t see an immediate cause and effect. It may be many years before on-the-job exposures result in firefighter health issues. And not every firefighter is going to develop issues from on-the-job exposures. It’s a biological lottery.
In that regard, getting firefighters to change their post-fire behaviors (e.g., gross decon of PPE, keeping dirty PPE out of the cab, showering and changing clothes immediately upon returning to the station) is similar to the challenge that our predecessors faced in getting firefighters to wear SCBA while fighting structure fires in the 1960s and 1970s.
Back then, what we knew about the dangers of breathing smoke (e.g., heart and lung diseases) was just coming to light. Getting consistent information was difficult to obtain, and speculation often filled in the gaps. This was further complicated by the fact that fire departments faced fiscal challenges getting adequate numbers of SCBA. And even in those departments that had SCBA, the culture suppressed its use, giving rise to such braggadocio statements as “real firefighters eat smoke” (and others that can’t be repeated here). The veteran firefighter who came out of a tough job with soot all over his face and blowing black snot out of his nose was the idol of every new firefighter.
Eventually, SCBA use became more routine in most fire departments – but only after untold numbers of firefighters suffered and even died from diseases that might have been prevented had they used the SCBA provided to them.
A new approach: Communications intervention
In the aforementioned study, “The Invisible Danger of Bunker Gear Transfer,” researchers conducted a study involving 141 firefighters from Palm Beach County (Florida) Fire Rescue (PBCFR) across nine PBCFR stations to see the effects of a theory-based communication intervention that focused on increasing post-fire decontamination behaviors.
The researchers used the Integrated Model of Behavioral Prediction (IMBP), which assumes that when given information, most people are rational thinkers who process the information and the corresponding underlying rationale and then make a conscious decision to adopt, or not adopt, a certain behavior.
According to IMBP, there are three determinants that could significantly predict an individual’s behavioral intentions: attitude, perceived norms and self-efficacy:
- Attitude refers to our evaluation of how favorable or unfavorable the outcome will be if we enact a certain behavior. The more someone believes a specific behavior will lead to outcomes that are positive – and good/favorable for the individual – the greater the possibilities that they will adopt the behavior. (Back to the veteran firefighter and their lack of SCBA use. Firefighters, especially younger and more impressionable ones, had a positive attitude toward such a firefighter and wanted to be just like them.)
- Perceived norms refers to the social pressure one feels to perform or not perform a behavior. The stronger the perceived norm is, the stronger the behavioral intention is. With their cultural emphasis on trust and reliability, perceived norms are likely to heavily influence behavior in fire departments.
- Self-efficacy is your belief in your ability to solve a problem, reach a goal, complete a task, and achieve what you set out to do. For example, a student who has a high level of self-efficacy in mathematics will feel confident in their ability to do well in a tough statistics class. The PBCFR firefighters in the study identified barriers in both policy and practice toward decontamination processes – barriers that decreased their perceptions of self-efficacy.
Following the IMBP model, attitudes, perceived norms and self-efficacy jointly determine the strength of an individual’s intention to perform a certain behavior, and this behavioral intention is the single strongest factor in predicting actual behavior.
6 elements of intervention messages and materials
In the PBCFR case, the research team’s research included 150+ hours of ride-alongs with firefighters at 15 different fire stations; facilitation of four focus groups with a cross-section of firefighters of different ranks; and multiple meetings with key subject-matter experts within the department.
This approach enabled researchers to use principles of communication design to create messages and interventions specifically suited for PBCFR personnel. This collaboration, which actively involved researchers and firefighters, developed (and focus groups tested prior to implementation) six primary elements to the intervention:
1. Having deemed that discussion of firefighters and cancer, and identification of accurate firefighter risk were of primary importance, these messages were designed to provide more realistic information on cancer risk and susceptibility to help correct the overly fatalistic views held by many firefighters.
2. Messages, which included quotes from firefighters to add credibility and relevance, were crafted to discuss dirty PPE and how the fire service culture continues to underpin “dirty gear as a badge of honor.” Those messages were designed to show that both fire service norms and culture were shifting toward keeping PPE clean to help reduce exposure risk.
3. Using the type of invisible dye usually found in bank robberies, the teams created a five-minute video that showed firefighters fighting a fire, transporting dirty PPE back to the station, activities around the station, contamination from hauling PPE in a personal vehicle, and cross contamination from activities with children. The video proved to be a powerful tool that visually demonstrated the high degree of susceptibility and severity of exposure of carcinogens to PBCFR personnel when dirty PPE is not properly managed from scene to storage.
One key takeaway from the video was that it took a page out of the book, “Don’t bite off more than you can chew.” While it clearly showed what the problem was, and discussed the need for improved decontamination practices, it didn’t tackle the “how that should be accomplished.”
4. The teams conducted discussions to better understand key barriers firefighters voiced in the focus groups about cleaning gear, and provided messages to show how those barriers were either false or could be overcome. Researchers had identified that there are both actual and perceived barriers to conducting the desired decontamination processes, including:
- Available time to perform decontamination;
- Fears of wet gear and getting steamed (heat from a fire causing water in the gear to turn to steam, burning the firefighter); and
- Difficulties in accessing washer/extractors and/or exchanging dirty gear for clean gear.
5. A second video, this one 10-minutes long, was developed to show the process for post-fire decontamination of PPE that the fire department was preparing to implement. The video featured interviews with highly admired firefighters within the department, discussions of the need (and existence) of cultural change, and discussions of the cancer risk.
6. The teams created visual media – posters, refrigerator magnets and bumper stickers – to promote the desired new behaviors (e.g., the seven steps of the post-fire decontamination process) and new perceived norms (“Clean gear is the new badge of honor”). The department collaborated with advertising and public relations practitioner faculty, communication researchers and its firefighters to address cultural preferences and overall information needs of its personnel.
Study results on PPE compliance
After all of the interventions had taken place – across nine fire stations and involving 141 firefighters – researchers found statistically significant increases in the attitudes of involved personnel; acceptance of new norms; self-efficacy among participants; participant intentions to engage in decontamination processes; and decreases in perceived barriers to post-fire decontamination efforts.
A workable strategy to replicate
We waited far too long for the changes in attitude, perceived norms and self-efficacy that had to occur before SCBA use by firefighters became the new “normal” to passively evolve. During that time, untold numbers of firefighters succumbed to early deaths from heart and lung disease, likely precipitated by their constant exposure to smoke without respiratory protection.
Your big takeaway from this article should be that we don’t have to wait, nor can we afford to wait, for the new normal for post-fire decontamination practices to evolve. Firefighters are suffering and dying from cancer, and more are being diagnosed, daily.
The authors of this study, and the members of the PBCFR, have provided a workable strategy with a demonstrated success that can be replicated in other fire and EMS departments. It’s now up to the rest of us to take up the task of proactively constructing the new normal in each of our departments.
The views of the author do not necessarily reflect those of the sponsor.