A Full Toolbox

Within the last 10 years, an emergence of research exploring firefighter sleep has indicated that most firefighters experience inadequate sleep. Firefighters in Finland report sleep disturbances after working more than 50 hours in a week1. Mehrdad, Haghighi, and Esfahani found 69.9% of firefighters report poor sleep quality2 compared to 37% of the general adult population in Tehran.3 A study of South Korean firefighters found 51.6% of shiftwork firefighters suffer poor sleep quality compared with 38.5% of non-shiftwork firefighters.4 Researchers found 59.3% of Iranian firefighters report poor sleep quality.5 Billings and Focht found 73% of firefighters among six South Central US fire departments report poor sleep quality.6

Firefighter Actigraphy
Figure 1: Firefighter Actigraphy
It is generally understood that anticipating and responding to emergencies during the night disrupts sleep duration and sleep quality (Figure 1) compared to non-work nights. While responders may recover sleep at home, the continual “all-nighter” creates a greater risk for adverse outcomes. Research consistently associates poor sleep with acute and chronic health impairments, which would ultimately decrease firefighter performance. It makes sense why sleep has been labeled the fourth pillar of health7 accompanied by a healthy diet, physical activity and mental wellbeing.

The concessions to normal safety rules assume fire and emergency responders have a high level of alertness and performance. While working during the night reduces sleep opportunity and disrupts circadian rhythm, it may be possible to improve the quality of sleep one receives. Figure 2 illustrates the relationship of sleep to organizational characteristics, sleep environments (home and work), individual behaviors, mental health, physical health, physical performance and cognitive performance.

Relationships of sleep
Figure 2: Relationships of Sleep

While certain indicators may directly affect sleep duration and quality, some factors in mental health, physical health and individual behaviors may be bidirectional, meaning one can influence the other and vice versa.

Fire and emergency services is a high-risk occupation. Members within this profession do not always operate in protected environments, so it is likely many are exposed to varying degrees of stressors throughout their career. Each shift, they face an uncertain level of harm, from the routine public assist to the mass casualty incident. Thus, in addition to medical skills, Fire/EMS, police, and other emergency responders need a tool chest of psychological skills.8-9

Such continued and cyclical experienced trauma can result in ongoing PTSD, or what academics term persistent PTSD.10 Those facing ambiguity cope by 1.) focusing on alleviating a direct issue, or 2.) trying to find meaning for an event that occurred. The latter, termed pervasive ambiguity, may lead to searches of “why” something happened.11 Persistent PTSD has been found to result in: ongoing posttraumatic symptoms (increased anxiety, hypervigilance and),10,12-13 behavioral conditions (avoidance activities like overuse of drugs and alcohol, and loss of sleep),14-15 and health conditions (obesity, autoimmune and cardiovascular disease).16-17 PTSD can result in rumination and insomnia, which can eventually snowball into more severe adverse impacts. In addition, the cyclical nature of the profession may repeatedly expose responders to trauma. If left unaddressed, the trauma effects may be more difficult to mitigate18-20 placing firefighters, their co-workers and the community at risk.

While such trauma may adversely affect responders, experiences may also prepare them to be better at their jobs. People experiencing persistent PTSD can have enhanced self-determination and may positively impact their communities.21-22 When not completely overwhelmed by an experienced trauma, responders can learn from their experiences to prepare for future situations. Essentially, the more tools they have, the better.

Sleep is the central connection in the web of human functions. It relates to physical and mental health, but is often overlooked. Sleep should become a priority for responders and organizations because with improved sleep, diet, physical activity and mental wellbeing, fire and emergency services responders will be better prepared to perform tasks, process exposures and recover from shiftwork – improving their resilience for future events.

by Joel M. Billings, Ph.D. and Allison Kwesell, Ph.D.


  1. Lusa, Sirpa, Marketta Häkkänen, Ritva Luukkonen and Eira Viikari-Juntura. (2002). Perceived physical work capacity, stress, sleep disturbance and occupational accidents among firefighters working during a strike. Work & Stress, 16(3):264-274.
  2. Mehrdad, Ramin, Khosro Sadeghniiat Haghighi and Amir Hossein Naseri Esfahani. (2013). Sleep quality of professional firefighters. International journal of preventive medicine, 4(9):1095.
  3. Asghari, Alimohamad, Mohammad Farhadi, Seyed Kamran Kamrava and Babak Ghalehbaghi. 2012. Subjective sleep quality in urban population.Archives of Iranian medicine 15(2):95.
  4. Lim, D. K., K. O. Baek, I. S. Chung and M. Y. Lee. (2014). Factors related to sleep disorders among male firefighters. Ann Occup Environ Med, 26(1):1-8.
  5. Abbasi, Mahnaz, Majid Rajabi, Zohreh Yazdi and Ali Akbar Shafikhani. 2018. Factors affecting sleep quality in firefighters. Sleep and Hypnosis, 20(4):283-289.
  6. Billings, Joel and Will Focht. 2016. Firefighter shift schedules affect sleep quality. Journal of Occupational and Environmental Medicine, 58(3):294-298.
  7. Duncan, Dustin T, Ichiro Kawachi and Susan Redline. The social epidemiology of sleep. In, edited by: Oxford University Press, 2019.
  8. Steadman, H. J., Deane, M. W., Borum, R., & Morrissey, J. P. (2000). Comparing outcomes of major models of police responses to mental health emergencies. Psychiatric Services, 51(5):645–649.
  9. World Health Organization. (2009). Preventing Suicide: A resource for police, firefighters and other first line responders.
  10. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4):319–345.
  11. Ball-Rokeach, S. J. (1973). From Pervasive Ambiguity to a Definition of the Situation. Sociometry, 36(3):378–389.
  12. Friedman, M. J. (2007). PTSD history and overview. United States Department of Veterans Affair [Available Online].
  13. Thabet, A. A., Tawahina, A. A., El Sarraj, E., & Vostanis, P. (2008). Exposure to war trauma and PTSD among parents and children in the Gaza strip. European Child & Adolescent Psychiatry, 17(4):191–199.
  14. Sestito, S. F., Rodriguez, K. L., Saba, S. K., Conley, J. W., Mitchell, M. A., & Gordon, A. J. (2017). Homeless veterans’ experiences with substance use, recovery, and treatment through photo elicitation. Substance Abuse, 38(4):422–431.
  15. Ueda, Y., Yabe, H., Maeda, M., Ohira, T., Fujii, S., Niwa, S., Ohtsuru, A., Mashiko, H., Harigane, M., Yasumura, S., & the Fukushima Health Management Survey Group. (2016). Drinking behavior and mental illness among evacuees in Fukushima following the great east Japan earthquake: The Fukushima health management durvey. Alcoholism: Clinical and Experimental Research, 40(3):623–630.
  16. Bookwalter, D. B., Roenfeldt, K. A., LeardMann, C. A., Kong, S. Y., Riddle, M. S., & Rull, R. P. (2020). Posttraumatic stress disorder and risk of selected autoimmune diseases among US military personnel. BMC Psychiatry, 20(1):1–8.
  17. Ryder, A. L., Azcarate, P. M., & Cohen, B. E. (2018). PTSD and physical health. Current Psychiatry Reports, 20(12):1–8.
  18. Back, S. E., Flanagan, J. C., Jones, J. L., Augur, I., Peterson, A. L., Young- McCaughan, S., Shirley, D. W., Henschel, A., Joseph, J. E., & Litz, B. T. (2018). Doxazosin for the treatment of co-occurring PTSD and alcohol use disorder: Design and methodology of a randomized controlled trial in military veterans. Contemporary Clinical Trials 73:8–15.
  19. Brazil, A. (2017). Exploring critical incidents and postexposure management in a volunteer fire service. Journal of Aggression, Maltreatment & Trauma, 26(3):244–257.
  20. Flannery, R. B. (2020). Psychological trauma and the trauma surgeon. Psychiatric Quarterly, 1–7.
  21. Bonanno, G. A., Brewin, C. R., Kaniasty, K., & Greca, A. M. L. (2010). Weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities. Psychological Science in the Public Interest, 11(1):1–49.
  22. Calhoun, L. G., & Tedeschi, R. G. (1998). Posttraumatic growth: Future directions. In Posttraumatic growth (pp. 217–240). Routledge.

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