1108 SUPPLEMENT
jurisdictions by state or local laws. The standards should not be
used as rigid criteria to evaluate the quality of the programs or
facilities. They were developed to represent neither the minimal
acceptable level of performance nor a platonic ideal but rather to
occupy the area between minimal acceptable practice and the
ceiling beyond which additional effort and expertise would not
yield commensurate improvements in health and safety. As new
knowledge and innovative practices evolve, the standards
them-selves should be modified and updated.
SUMMARY
Caring for Our Children represents a model collaboration of
government, voluntary health associations, and individuals in a
national aspiration to create in every child-cane setting a safe,
healthful, and nurturing environment for our children, our most
valuable resource and our future.
ACKNOWLEDGMENTS
Parts of the article are from the “Introduction” by Albert
Chang, MD, MPH and George Sterne, MD in “Caring for Our
Children-National Health and Safety Performance Standards: Guidelines
for Out-of-Home Child Care Programs.” Reprinted with permission.
REFERENCES
I. National Research Council Report. Who Cares for America’s Children?
Child Care Policy in the 1990s. Washington, DC: National Academy of Sciences; 1990
2. American Public Health Association and American Academy of Pedi-atnics. Caring for Our Children-National Health and Safety Performance
Standards: Guidelines for Out-of-Home Child Care Programs. Washington, DC, and Elk Grove Village, IL: APHA/AAP; 1992
Training
To
Ensure
Healthy
Child
Day-Care
Programs
Abby
Shapiro
Kendrick,
MEd
Training in child care assumes a number of forms. There is
pre-service training (needed before entering the field); orientation
training (received when first on the job, highlighting the most
essential skills, tasks and knowledge needed to begin the job); and
ongoing training (required by regulation or recommended
peri-odically for current staff).
Despite the fact that training is known to have a positive effect
on the field of early care and education, the current training
system is fraught with problems. A 1991 national survey
con-ducted by the Wheelock College Center for Career Development
in Early Care and Education found that at least one of three key
informants in 59% of states said “training is fragmented, random, scattershot, and not based on the needs of the field.”
The licensing system requires minimal training and experience. For teachers in child-care centers, five states require no training,
four states require pre-service training, 29 states require only
ongoing training, and 14 states require both pre-service and
on-going training. Few states require more than 10 hours of annual
ongoing training for any child-care professionals. For family
child-care providers, the numbers are even lower: 24 states require no
training and only 12 states require annual ongoing training.’ If
first aid and cardiaopulmonary resuscitation (CPR) certification are required, there is little time for any other training.
In addition to limited funds to support training and limited
incentives for providers, administrators, on funders to invest in
training, other well-known barriers to implementing systematic
and coordinated training efforts include the following items:
. high cost of classes;
. providers’ lack of time as they juggle long working hours,
family obligations, and sometimes second jobs necessary for
financial survival;
. lack of access to affordable training, in convenient locations,
and offered during evenings or weekends;
. training that does not meet the needs of participants; and
. few career development opportunities due to lack of credits for
training.’
Inherent problems of the training system are intimately tied to
the societal lack of respect for child cane and the misperception that child-care jobs are unimportant. Clearly, the astoundingly
high rates of turnover found in one national study-41% among
all child-care staff-and the poor ability to recruit and retain staff are directly attributable to poor wages and low professional status
of what are perceived as “dead-end” jobs.
From the Program Manager, Work/Family Directions, Boston, Massachu-setts.
Use of trade names is for identification only and does not constitute en-dorsement by the Public Health Service, the Centers for Disease Control and Prevention, or any of the other cosponsors of this conference.
Despite the fact that the training system is in disarray, training
is still known to have a direct impact on quality. A number of
non-health-based studies have shown that the critical determinant of high-quality child care is the continuity of appropriately trained adults. This finding can be generalized to health training. Galinsky
found that children who have positive relationships with a care
giver have higher self-esteem and feel “special and unique, the
foundation of social and emotional health.”3 Phillips, McCartney,
and Scarr have found that positive social and cognitive
develop-ment are correlated with verbal stimulation by adults.4
Conversely, children in low-quality child-care environments
have lower language and social skills than those in high-quality settings.2
Several studies have documented that even small amounts of
specialized training positively influence care-giving behavior in
centers and in family child-care settings. Ruopp, Travers, Glantz,
and Coelen5 and Phillips and Howes6 documented positive impact
of even small amounts of specialized training on care-giving
be-havior for both family day-care providers and care givers in
centers.
From the body of health-care literature, there is also evidence
that training can have a substantial impact on program
compli-ance with health standards. Black’s study in 1981 compared two
centers that implemented hand-washing programs with two
con-trol centers that did not. After the program began, the incidence of
diarrhea at the hand-washing centers fell and after 2 months
continued to be lower than at the control centers.7 The incidence of diarrhea was approximately half that of the control centers for the entire 35-week study period.7
Aronson studied the effects of a 72-hour training program for
child-care staff on becoming health advocates. Pretraining
assess-ment of programs in which the trainees worked indicated a
wide-spread need for improvement on measured health standards.
Centers that participated in the program-monitoring aspects of the
study only showed improvements in compliance, but those that
also received training achieved greater compliance with health
measures. The training was also successful in increasing health
knowledge of the advocates and their advocacy activities.8
The American Public Health Association and American
Acad-emy of Pediatrics (APHA/AAP) National Health and Safety
Per-formance Standards offer guidelines for topics and amount of
training. According to the Standards, directors and all care givers shall have at least 30 clock-hours per year of continuing education
in the first year of employment-16 in child-development
pro-gramming and 14 in health, safety, and staff health. Thereafter,
each shall have 24 clock-hours per year, depending on
compe-tency needs-16 in child-development programming and eight in
health.9
The APHA/AAP guidelines also call for an initial orientation to
acclimate the new staff person to the basic policies and procedures of the program, including children’s needs, discipline, relating to
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SUPPLEMENT 1109
parents, emergency procedures, basic hygiene practices, and child
abuse. Additional orientation within the first 3 months includes a
more in-depth look at essential topics such as infection control
procedures and daily health assessments.
The Child Development Associate (CDA) is a nationally
recog-nized competency-based training and credentiaffing system. The
first stated goal is to establish and maintain a safe, healthy
learn-ing environment. This goal assumes that staff provide a safe
environment to prevent and reduce injuries; promote good health
and nutrition; provide an environment that contributes to the
prevention of illness; and use spatial relationships, materials, and
routines for constructing an interesting, secure, and enjoyable
environment that encourages play, exploration, and learning.’#{176} All training in child care should relate to goals and competencies, which in turn are related to all areas of the child’s development,
positive relationships with families, program management, and
professionalism.
Good training with essential content does make a difference.
The approach, however, is just as important as the content.
Un-fortunately, even with the best intentions, trainers can fail to make
a positive impact. To be effective, training must be conducted
appropriately and respectfully. What does this mean? All too
often, child-care providers have reported that a trainer showed
slides of charts and research data, spoke in terminology that they
had never heard before, and left them boned and still ignorant of
the real issues.
On a personal note, having come from an early childhood
background, I was exposed to a new vocabulary when I began to
work at the Massachusetts Department of Public Health. A word
like “fomites” baffled me (I thought materials in classrooms were
toys!); terms such as “fecal coliforms,” “morbidity frequency,” and
“epidemiological studies” were dizzying. I quickly learned that I
needed to master this foreign language and jargon to survive in
the health world. Yet had I used
these
same
terms withoutdefi-nition when I conducted training in the child-care world, I would
have lost both my credibility and my impact.
I believe firmly that to be effective, trainers must learn the
context in which care givers work every day. Trainers must speak
the care-givers’ language in order to be understood and must
understand child-care dilemmas in order to be believed. To
de-liver training or consultation effectively in child-care settings, one
must first visit centers, family child-cane homes, or both to
en-counter the realities of the field today. It is unacceptable to lecture
care givers in centers about the virtues of hand washing, for
instance, without understanding that the sink may be 50 feet down
the hall and teachers cannot leave their classrooms staffed below
the ratios dictated by state regulations. One must be prepared to
offer real and practical solutions to the fact that the sink is down the hall.
Adults can be forced to attend training, but they cannot be
forced to learn. Programs need to be designed to encourage input
from people with different life experiences, values, and cultural
backgrounds. In order to integrate the training with previous
knowledge, there must be active participation by the students.
Research on adult learning needs and styles reveals that adults,
like young children, learn best in situations that are interactive
and experiential, allowing time for sharing and processing;
par-ticipants must be able to generalize principles from the training
environment to the “real world.” The Table describes 10 elements
of good training.
Wolfe recently reported her findings from a study of most
commonly used forms of training, preferred forms of training, and
training that changes behavior. The most preferred forms of
train-ing were small group discussion of handouts, demonstrations and
modeling, games and simulation, observation of actual practice,
role play, and video presentations. Changes in behavior were
reported when the content of training met a need, when it was
focused and needs-based, when there were handouts for later
reference, when the information could be used to apply theory
into practice, when there was support from the administration,
and when a variety of training techniques were used. Methods
that caused least change in behavior were worksheets, panel
dis-cussions, and homework assignments. Students most preferred
instructors who were well-prepared, knowledgeable, hands-on,
enthusiastic, energetic, and who used a variety of techniques.”
I have some practical suggestions and examples to offer that
illustrate the type of training I commend. Let us return to the topic
of hand washing. For example, in the middle of a training
work-TABLE. Elements of Good Health Training
I. Audience assessment
Awareness of an audience’s particular needs is essential.
2. Trainer familiar with child care and content geared to
needs
A trainer must understand the context in which care givers work
every day, because focused, needs-based training results in
changes in behavior.
3. Convenience
Time, location, quality of space, and affordability all affect the
success of a training program.
4. Professionalism
Acknowledgement of child-care workers as professionals should be
made clear.
5. Overplanning
It is crucial to have a wide range of training options prepared to
meet the needs of a particular audience.
6. Interactive and experiential activities
Participatappreciate, and learn effectively in, small group
discussions, games, case study reviews, role play, demonstration
and repeat demonstration, interactive and experiential learning, and practice and skill checks.
7. Realistic, practical, concrete information
Participants must be able to generalize principles to the “real
world” and trainers must offer specific, appropriate techniques
and solutions.
8. Varied activities
Just as one would pace a child’s day with active and quiet
activities, it is important to provide a balance of activities for
adults. A variety of approaches and media enrich training
sessions.
9. Incentives and rewards
These are very useful to motivate trainees, even if small tokens
such as certificates of completion and prizes are offered.
10. Supervisors’ and co-workers’ “buy-in” and attendance
To create opportunity for change and to ensure that changes
continue to be realized, supervisors should attend training,
support the training, or both, even after it has been completed.
shop, I have donned my favorite sweatshirt, which boldly says,
“Wash your Hands, Wash your Hands, Wash your hands!” I have
met former trainees years later who have said to me “Aren’t you
the lady who wore the hand washing sweatshirt? You know, I
really changed my habits after that workshop!” Obviously, the
sweatshirt alone did not create that impact; it was simply a
con-stant visual cue.
In the workshop format, I also used another highly effective
visual and hand-on experience with Gb-Germ , a substance that
simulates germs on hands and surfaces. In a very concrete and
memorable way, care givers actually see the “germs” left on their
hands, in the webs of their fingers, under their jewelry, and on the
backs of their hands and wrists after they wash their hands
improperly. They see the “germs” left on the faucet and the sink
surfaces when they do not turn off the faucet with a paper towel.
This experience makes a lasting impression.
An example of family child-cane training is the Family Child
Health and Safety Checklist package now available from Redleaf
PreSS) This training package includes a comprehensive checklist
for a family child-cane provider to use when checking her home.
The list includes known significant health and safety risks and
explains to the provider not only the risk associated with the item (eg, hot water >120#{176}F), but also offers some practical solutions to
the problems. Also included in the package is a no-choke test tube
and a water temperature gauge. An 18-minute videotape
high-lights the information contained in the checklist.
The materials are based on work done by the Family Day Care
Health Project funded through a federal Maternal and Child
Health (MCH) SPRANS grant to the Massachusetts Department of
Public Health. While at the department, I was approached by a
private consulting firm that had become aware of two deaths of
toddlers in family child-care settings in locations in which this
group was funding provider recruitment campaigns. One death
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1110 SUPPLEMENT
resulted from suffocation in a toy chest; the other was caused by a
blow from a heavy swing. These deaths were clearly preventable;
providers must have access to sound and meaningful training
op-portunities before or soon after they enter the field. With corporate funding through the consulting firm, the materials were field tested,
produced, and distributed along with a workshop curriculum to
Child Care Resource and Referral agencies throughout the country.
Health departments and licensing agencies have been active in
supporting child-cane training. Some offer consultation, technical assistance, and traimng some have written manuals and “tip sheets.”
Child-care resource and referral agencies must play a vital role in
promoting health and disseminating health training and resources.
Preliminary recommendations to improve these problems from
the Center for Careen Development suggest systemic planning,
regular public funding, a progressive role-related system, quality controls, and recognition and rewards.
In summary, good, appropriate, respectful training can make
an appreciable difference in the quality of health and safety
poli-cies and practice. The myriad of other excellent resources could
not be described in this paper. I recommend a national repository
of training materials from which all training data, models, and
curricula can be assessed and accessed.
Health-cane providers, child-care providers, and families must
form an integral partnership and communicate regularly to benefit individual children. From a programmatic and policy perspective,
the child-cane community needs and desires the rich array of
skills, talents, and resources that health providers have to offer.
However, health professionals must recognize the wealth of
in-formation and discovery available to them in the child-care field;
one benefit from teaching is that health professionals can learn
from child-care experiences. I challenge health professionals to
become partners with child-care professionals in training efforts.
Together, we can train other trainers to disseminate our vital
child-care health messages throughout the world.
REFERENCES
I. Costley J, Genser A, Goodman I, Lombardi J, McGenser B, Morgan G. The State ofthe States Report. Boston: Wheelock College; 1992 (in draft) 2. Whitebook M, Howes C, Phillips D. Who Cares? Child Care Teachers and
tl,e Quality of Care in America: Final Report of the National Child Care Staffing Study. Oakland, CA: Child Care Employee Project; 1989
3. Galinsky E. What really constitutes quality care? Child Care Info Lx-change. 1986;51 :41-47
4. Phillips C, McCartney K, Scarr S. Child care quality and children’s development. Dcv Psychol. 1987;23:537-543
5. Roupp R, Travers J, Glantz F, Coelen C. Children at the Center: Final
Report of the National Day Care Staffing Study. Cambridge, MA: Abt
Associates, Inc; 1989
6. Phillips DA, Howes C.Indicators of Quality Child Care: Revieu’ ofthe Research.
Quality in Child Care: What Does the Research Tell Us? Washington, DC:
National Association for the Education of Young Children; 1987;1 7. Black RE, Dykes AC, Anderson KA, et al. Handwashing to prevent
diarrhea in day-care centers. Am I Epist. 1981;1 134:446-451
8. Aronson 55, Aiken SA. Compliance of child care programs with health and safety standards: impact of program evaluation and advocate train-ing. Pediatrics. 1990;652:318-325
9. American Public Health Association, American Academy of Pediatrics.
Caring for Our Children. Washington, DC: APHA/AAP; 1992 10. Child Development Associate Assessment System and Competency Standards,
Preschool Caregivers. Washington, DC: Council for Early Childhood Pro-fessional Recognition; 1990
I I. Wolfe B. Presentation at The Early Childhood Profession Coming To-gether, from the First Annual Conference of NAEYC’s National Institute for Early Childhood Professional Development. June 4, 1992, Los An-geles, CA
12. Kendrick AS, Gravell J. Family Child Care Health and Safety Checklist. Massachusetts Department of Public Health. Boston: Redleaf Press; 1991
American
Public
Health
Association/American
Academy
of Pediatrics
National
Health
and
Safety
Guidelines
for
Child-Care
Programs:
Featured
Standards
and
Implementation*
Debra
Hawks,
MPH;
Joan
Ascheim,
MSN,
PNP;
C.
Scott
Giebink,
MD9J;
Stacey
Graville,
RN,
MNII;
and
Albert
J.
Solnit,
MD**
In response to the potential for illness and injury in group
cane for children and a growing need for national guidance on
health and safety aspects of child cane, the American Public
Health Association (APHA) and the American Academy of
Pediatrics (AAP) developed national health and safety
guide-lines for child-care programs. This collaborative effort
culmi-nated in the publication, Caring for Our Children-National
Health and Safety Performance Standards: Guidelines for
Out-of-Home Child Care Programs.’
From the APHA/AAP Child Care Standards Implementation Project,
American Public Health Association, Washington, DC; §Children’s
Corn-munity Bridge Project, Office of Family and Community Health, New
Hampshire Department of Health, Concord, NH; lDepartment of
Pedi-atrics and Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, MN; IlCommunicable Disease Program, Whatcorn County Health Department, Bellingharn, WA; **Department of Mental health,
State of Connecticut, Hartford, CT; Yale Child Study Center, New
Haven, CT.
‘See also “American Public Health Association/American Academy of
Pediatrics National Health and Safety Guidelines for Child-Care Pro-grams: An Overview,” page 1 107, and “American Public Health Associ-ation/American Academy of Pediatrics Injury Prevention Standards,” page 1046.
The APHA/AAP guidelines address the following technical
content areas:
. environmental quality;
S prevention and control of infectious diseases; S injury prevention and control;
. general health;
S nutrition;
. prevention and management of child abuse;
S staff health;
. children with special needs;
. health concerns related to social environment and child
development;
. health and safety organization and administration.
While all of these content areas are important in terms of health and safety, some tend to receive more attention. Certain standards
in each of the featured content areas are highlighted on the basis
of the perceived significance to care givers and health profession-als; the reflection of new knowledge and state of the ant; possible controversy; on considerations for implementation.
HEALTH CONCERNS RELATED TO SOCIAL
ENVIRONMENT AND CHILD DEVELOPMENT
This technical area describes the standards on social
environ-ment and child development in the service of promoting physical
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1994;94;1108
Pediatrics
Abby Shapiro Kendrick
Training To Ensure Healthy Child Day-Care Programs
Services
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Pediatrics
Abby Shapiro Kendrick
Training To Ensure Healthy Child Day-Care Programs
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the World Wide Web at:
The online version of this article, along with updated information and services, is located on
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American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1994 by the
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
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