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11
The determinants of quality care: review and
research report
Margaret Sims
Research Team:
Associate Professor Margaret Sims, ECU
Dr Andrew Guilfoyle, ECU
Associate Professor Trevor Parry, UWA
Funded by Lotterywest

There is consensus around the world that young children must
experience high quality services, not only to ensure the best
possible future outcomes, but because children have the right to
the best possible present (Elliott 2004; Myers 2004; Wylie &
Thompson 2003). All children are found to benefit from high
quality early childhood programs, but those from disadvantaged
backgrounds demonstrate stronger advantages (Myers 2004). The
catchphrase the importance of the early years has now become a
call to arms: it is recognised worldwide that we must provide the
best possible services to young children and their families (Stanley,
Prior & Richardson 2005). However, there is not universal
agreement as to what constitutes best possible early childhood
services. Understandings of quality are value-based and change as
values change (Childcare Resource and Research Unit 2004).
Understandings are also different across cultures, religions,
contexts and the person or group making the judgment (Friendly,
Doherty & Beach 2006). Myers (2004, p.19) argues that different
cultures may expect different kinds of children to emerge from
early educational experience and favour different strategies to
obtain those goals. There is not a universal definition of quality: in
different times and places different kinds of practices are valued as
high quality.
Despite this, within the Western world, professionals assume at
least a basic common understanding (see Cryer, 1999 for example).
The European Commission Childcare Network attempted to define
these commonalities and came up with 40 quality targets (available
at www.childcarequality.org). Analysing the literature from a range
221
of European countries, Myers (2004) argues there is consensus
around quality components including safety, good hygiene, good
nutrition, appropriate opportunities for rest, quality of opportunity
across diversity, opportunities for play, opportunities for developing
motor, social, cognitive and language skills, positive interactions
with adults, support of emotional development, and the provision
of support for positive peer interactions. However, performance
indicators identifying how these principles play out in practice
differ in different contexts and with different levels of expectations
and resources. What is clear is that quality is multidimensional,
complex and multi-theoretical (Duigan 2005; Raban, Ure &
Wangiganayake 2003). Single indicators of quality are ineffective, as
quality outcomes for children are found to relate to a complex
interplay of many different factors (Buell & Cassidy 2001).
In this context of complexity and uncertainty, researchers
attempt to measure quality, and states attempt to regulate for
quality care. Research tools measuring quality tend to focus on
particular theoretical approaches to learning, for example the
developmentally appropriate practice approach (Walsh & Gardner
2005). At state level, regulations are introduced addressing certain
easily measured aspects of care. There is general agreement that
where regulations are strict, quality is enhanced and outcomes for
children are better (Gallagher, Rooney, & Campbell 1999; Mitchell
2002), so the assumption remains that regulations must be doing
some good. OKane (2005) agrees, arguing that regulations
contribute to enhancing quality practice, but they are not solely
responsible as there are a number of other factors coming into play.
She argues that it is easier to regulate structural factors than
process, and thus it is structural factors that are found in most
childcare regulations.
The differentiation between structural and process factors in the
quality debate is one that has been recognised for many years
(McCrea & Piscitelli 1990; Murray 1986; Phillips 1987). Structural
factors are thought to establish a foundation upon which quality
processes can occur (Phillips et al. 2000). A range of structural
variables have been recognised as contributing to quality. For
example group size and adult/child ratios have long been
recognised as important (Mitchell 2002; Rayburn 2002). Most
countries include these variables in their regulations, although
222
different countries accord them different levels of importance
(Cryer et al. 1999). Increases in levels of staff experience are linked
to improvements in quality, although van Ijezendoon et al. (1998)
indicate a ceiling effect, where staff who have been in the industry
for over 10 years are more restrictive in their practice and offer less
stimulation to children. Staff stability is also linked to improvements
in quality service delivery (Mitchell 2002).
Staff knowledge, gained through training, is a common
structural variable identified in regulations and considered an
important contributing factor in quality service delivery. Pre-service
training is linked to increasing quality, as is ongoing training and
support (Campbell & Milbourne 2005). Staff with higher levels of
training are found to engage in warmer and more responsive
interactions with children and these lead to improved child
outcomes (Connor, Son, Hindman & Morrison 2005). Staff with
higher levels of training are less authoritarian, less punishing, more
sensitive and demonstrate more positive interaction styles (Abbott
& Langston 2005; Arnett 1989; Burchinal Cryer, Clifford & Howes
2002; de Kruif, McWilliam & Ridley 2000). Some research suggests
that training beyond high school level is related to improvements in
childrens social development (Loeb, Fuller, Kagan & Carrol 2004).
However, other research suggests that while training improves
childrens cognitive development it does not impact as positively on
socio-emotional outcomes (van Ijzendoorn 1998). Significant
improvements in childrens outcomes can be found when training
is coupled with on-the-job support, such as mentoring (Fiene 2002).
Training gives staff the knowledge and skills to participate in
warm, sensitive and responsive interactions with children and it is
these interactions and relationships that are important
determinants of childrens outcomes (Hutchins & Sims 1999; Wylie
& Thompson 2003). Interactions and relationships are part of
process measures of childcare quality (Mitchell 2002). High quality
early childhood practice requires caregivers to engage with
childrens interests, to be responsive and to stimulate children
(Connoret et al. 2005; Kugelmass & Ross-Bernstein 2000; Mitchell
2002; van Ijzendoorn et al. 1998; Zaslow & Tout 2002). Group-
related sensitivity is linked with secure attachments between
caregivers and children in childcare centres (Ahnert, Pinquart, &
Lamb 2006). Sensitive and responsive caregiving is linked with
223
improved cognitive outcomes for children (Loeb et al. 2004). In low
quality centres there are less adult-to-child interactions and less
child-to-child interactions, limiting learning opportunities for the
children concerned (Vernon-Feagans & Manlove 2005). Where
interactions are more controlling, children demonstrate less active
engagement, again limiting learning opportunities (de Kruif,
McWilliam & Ridley 2000). A number of childcare programs
recognise the importance of establishing secure relationships with
caregivers and operate using a primary caregiver model where
children are encouraged to develop positive relationships with
particular caregivers, who are then able to work with the children
over an extended period of time (Rayburn 2002).
Other process factors also contribute to a high quality childcare
service. Working collaboratively as part of a team (caregivers both
supporting each other and working with parents) is recognised as
an important indicator of a quality service (Landerholm, Gehrie &
Hao 2004). Caregivers need to demonstrate a range of skills to
ensure they can participate as an effective team member; these
include ability to collaborate, work in a team, share decision-making
and problem solving, and manage conflict resolution effectively
(Kugelmass & Ross-Bernstein 2000).
Working with parents requires recognising the importance of
communication. Childrens outcomes are enhanced when there is
congruence in values and practices between the home and the care
environment. Bronfenbrenner called this a strong mesosystem
(Bronfenbrenner 1979). Where children come into the care
environment from different cultural backgrounds than those of the
caregivers they are particularly at risk and it is important, in a
quality service, that these differences are recognised and addressed
(Wise & Sanson 2003).
The way the service is auspiced is also found to have an
influence on quality. Canadian research consistently demonstrates
that for-profit centres consistently demonstrate lower levels of
quality than community-based services (Cleveland & Krashinsky
2005). In Canada, this lower quality is linked to the use of more
untrained staff in for-profit centres, along with higher staff/child
ratios and higher staff turnover rates. These result in poorer
performance on quality indicators such as the level of personal care
provided for children, use of materials, activities, interactions
224
between staff and children, communication with families and
support for staff professional development. It is often argued that
such factors do not play such a part in Australia because of
regulatory control over staff/child ratios and the number of trained
staff. However, a recent study of quality in Australian child care
clearly identified lower levels of quality in corporate centres, higher
levels of quality in privately owned centres (as distinct from
corporate ownership of large numbers of centres), and highest
quality in community-based centres (Rush, 2006, see Rush in this
volume). Caregivers in community-based centres were found to be
more able to develop secure relationships with children,
accommodate individual needs, and more likely to offer nutritious
foods. Corporate centres were more likely to drop below mandated
staff/child ratios whereas community-based centres were more
likely to regularly operate at higher than required ratios. Five
percent of caregivers in community-based services and 21 percent
in corporate centre caregivers said they would not be happy to send
their own child (under two years of age) to a centre operating at a
similar level of quality as the one in which they were employed. It is
argued that the very nature of corporate enterprise makes it
impossible to offer the highest levels of care to children, as the
business orientation of for-profit enterprise is incompatible with the
humanist focus of community-based service delivery.
While it is recognised that many trained caregivers share a
common understanding of quality, not all are able to implement
that understanding in their practice (Watson 2003). Many issues
impact on caregivers ability to deliver high quality practice.
Caregivers own personal values and beliefs impact on the quality of
practice they deliver (Sims 1999, 2003b). Where caregivers receive
appropriate support the quality of service delivered improves and
thus child outcomes improve (Epstein 1999). Higher salary levels
for caregivers are linked to better quality ratings (Myers 2004).
Unfortunately in many Western world countries caregivers work in
an environment characterised by low wages and poor working
conditions (Doherty & Forer 2005). In Australia, for example, in
2003 caregivers working in the state of Victoria received the same
level of pay as garbage workers (Sumison 2005). Caregivers are
recognised as among the lowest paid workers in Australia, and
Australia spends only 0.1 per cent of GDP on early childhood
225
services, one of the lowest expenditures in the world (Elliott 2004;
OECD 2006).
The work of caring for children is not valued by the community.
In part this is associated with the history of childcare programs,
arising out of a social reform movement aimed at controlling the
lower classes, preparing lower class children for their appropriate
position in life (Brennan 1994; Hutchins & Sims 1999). The status
of child care is also deeply linked to patriarchy and the mythology
of motherhood: women are supposed to care for children because
it is in their nature to do so, and as such, it is not a professional
occupation but a natural and inevitable role all women should be
able to perform instinctively. Despite decades of feminism many in
our society are still strongly influenced by patriarchy. Indeed,
caregivers themselves are not immune and as recently as 20 years
ago Bell (1988) demonstrated that the majority of caregivers
thought parents using child care were selfish to do so, and did not
intend to ever put their own children into child care.
In this environment of poor wages, working conditions and
minimal value placed on their work, it is very difficult for
caregivers to implement high quality practice. They are
inadequately trained, paid, and supported. They may have the
knowledge, but often lack the material and emotional resources to
deliver. Research clearly demonstrates that workers in positions
where they have little control over their work, and who feel their
work is under-valued, experience increased levels of stress and this
impacts not only on their ability to perform, but on their long-term
health and wellbeing (Bollini et al. 2004; Kunz-Ebrecht,
Kirschbaum & Steptoe 2004).
Worker stress has been examined in a number of studies, using a
biomarker (cortisol) as an indicator of stress levels. Men in lower-
level positions demonstrate consistently higher cortisol levels,
increased heart rate and higher blood pressure than men in
executive or more senior positions during the course of their
normal daily lives. However, women in more senior positions
demonstrated higher levels of cortisol, suggesting that they
experienced more stress (and presumably stress-related illnesses)
than women in less responsible positions (Steptoe 2003b). Steptoe
also reports that blood pressure in workers in lower status positions
takes longer to return to baseline levels after a stressful event
226
(Steptoe 2003a). To date, caregivers working with children in their
early years, (years that are crucial in shaping outcomes for children
and society as a whole) have not been targeted in this research. This
chapter reports preliminary results on a project that examines the
stress levels caregivers experience in their normal daily work, and
links that to the quality of the services they offer young children.
This is part of a larger study of childrens cortisol levels in child care
and how these relate to the quality of the childcare program (see
Sims, Guilfoyle & Parry 2005, 2006a, 2006b)
The project examined the relationship between caregiver stress
(cortisol) levels, childrens stress (cortisol) levels, a range of
structural caregiver variables and childcare quality as measured by
process variables.
Methods
Sample
Caregivers in 16 childcare centres around Perth were approached
to participate in the study. All children attending each centre for at
least three days a week were approached to participate. To date, 42
babies (02 years of age), 67 toddlers (23 years) and 117 kindy
children (35 years) have been involved. Caregivers were asked to
provide information about their work with the children. They were
given the option of extending their involvement to a personal level
whereby additional data was collected as described below. This
chapter reports on data from the 41 caregivers to date who have
done so.
Cortisol
Cortisol is becoming a popular research tool because it provides a
measure of the immediate impact of the environment on the body
(Gunnar & Cheatham 2003). In a stressful situation, the body reacts
by increasing cortisol which functions to provide additional energy
to cope with the stressor. When stress is present chronically the
body becomes programmed to maintain high or low levels of
cortisol over much or all of the day. It is thought that constant high
levels of cortisol are linked to an active coping response and
constant low levels to a passive coping style (Gunnar & Vazquez
227
2001) but it is not yet clear how these different pathways are
established. It is clear from a range of both human and animal
research that chronically high or low levels of cortisol (hypo- or
hypercortisolism) are linked to a range of undesirable outcomes.
Children exposed to chronic stress in the early years of life develop
atypical stress responses that increase their lifelong risk for
hypertensive illnesses (heart attacks and strokes) and memory
problems (Abercrombie et al. 2003), severe rheumatoid arthritis,
chronic fatigue syndrome and impaired immune responsivity
(Padgett & Glaser 2003), depression and post traumatic stress
disorder (Young & Breslau 2004) and a range of social-emotional
(Luecken & Lemery 2004) and behavioural (Adam 2003) problems.
Given, therefore, that it is important children develop normal
cortisol responsivity, it is possible to define a high quality
environment as one in which childrens stress levels are low (Sims,
Guilfoyle & Parry 2005). Cortisol measures give researchers the
opportunity to identify quality in an environment without having to
address the values issues surrounding different understandings of,
and beliefs about, what constitutes quality. Quality becomes that
which operates to minimise childrens stress levels, in this case as
measured by salivary cortisol.
Saliva is commonly used in research as a vehicle to measure
cortisol levels as it is non-invasive and easy to collect, store and
transport. It does not decay quickly and does not need special
treatment (Gunnar & White 2001). Saliva samples in this study were
taken following the method outlined in Gunnar and White (2001)
and described in Sims, Guilfoyle and Parry (2006b). Saliva was
collected before morning and afternoon tea from the primary
(trained) caregiver and for each child in the group. The afternoon
cortisol scores of each caregiver were averaged then subtracted
from the averaged morning scores to identify the average increase
in cortisol for each caregiver. Morning and afternoon childrens
cortisol scores were averaged across the children in the group led
by each caregiver. These averaged afternoon cortisol scores then
were subtracted from the averaged morning cortisol scores to
identify the childrens average change in cortisol per group.
228
Childcare quality
Fourteen of the principles identified in the national Quality
Improvement and Accreditation System (QIAS) (National
Childcare Accreditation Council 2001a, 2001b) were selected to
represent quality of each childs experience in the room in the
childcare centre they attended. We purposively selected centres to
cover the full range of quality experiences (from unsatisfactory to
high quality), and our sample therefore has a higher proportion of
unsatisfactory groups than is the case for the childcare industry
nationally, so we do not claim that the centres in this study are
representative of Australian child care as a whole (see Sims,
Guilfoyle, & Parry 2006b for further explanation). Observations
were taken in each room of the centre and rated according to the
scale identified in QIAS (National Childcare Accreditation Council
2001b). A quarter of the observations were sent to a nationally
trained validator to check for accuracy of rating. Concordance
was 100 per cent. Scores across QIAS principles were totalled into
an overall score (range =1442; median 20). For ANOVA
(analysis of variance) analysis, the total scores were subject to a
median split technique classifying centres into low quality and high
quality centres.
Data anal ysis and results (1)
Cortisol patterns of caregiver and children within low quality
and high quality centres
While the trends identified in the data failed to reach significance
based on the current sample sizes, they are clear in their direction.
Ongoing data collection will provide the additional sample which
may enable demonstration of significance. Cortisol increases for
staff in high quality centres are greater (mean increase = 2.52) than
their counterparts in low quality centres (mean increase = 2.12). In
other words as the day progresses, caregivers in high quality centres
demonstrate greater increases in cortisol than caregivers in low
quality centres. However within those same centres, childrens
cortisol is lower in high quality centres (mean increase = 0.12)
relative to the cortisol increases in low quality centres (mean
229
increase = 1.32). Thus in high quality centres, caregivers are getting
more stressed as the day progresses but children are getting less
stressed. In low quality centres it is the children who are getting
more stressed as the day progresses and the caregivers who are
getting less stressed. Perhaps the stress of maintaining a high quality
environment elevates the cortisol of workers; however this is well
invested effort as the children within those centres benefit from
reduced cortisol levels in the afternoon when compared to their low
quality centre peers.
Data anal ysis and results (2)
Caregiver variables and their impact on caregivers cortisol,
childrens cortisol and QIAS scores
We performed a series of unconditional multiple linear regressions,
separately for personal caregiver variables, caregiver ratings of
relationships and environment within the centre, and centre
characteristics. The only caregiver variables that showed a
significant relationship with their cortisol levels were the number of
trained staff in the room, and the numbers of children with
disabilities and children from culturally and linguistically different
(CALD) backgrounds in the room. Older caregivers tended to have
higher stress levels, and caregiver stress levels are also higher when
there is more than one trained caregiver in a room. Adding
children with disabilities to the group also increases caregiver stress
but adding children from CALD has the opposite effect.
The analyses investigating caregiver variables and their
relationship to childrens cortisol levels found three significant
results: for caregiver experience, number of hours worked by the
caregiver each week and the number of trained staff in the room.
Children were less stressed when their trained caregiver had more
experience in child care (not necessarily at this particular centre)
and there were more trained staff available to them. However,
caregivers increased hours of work per week increased childrens
stress levels.
The analyses investigating the relationship between caregiver
characteristics and the quality of the service they were delivering (as
measured by the QIAS score) demonstrated significance on three
230
variables: the length of time the caregiver had worked at this
particular centre, the adult/child ratio in the room and the number
of children from CALD backgrounds in the room. The longer
caregivers had been employed at the one centre the more likely
they were to offer programs that rated highly on the QIAS. Better
adult/child ratios also improved performance on the QIAS as did
increasing numbers of children from CALD.
Discussion
Structural factors linked to childcare quality are controlled by
legislation in Australia (albeit at state level) and because of this it is
assumed that the variation we see in these elements is minimal and
therefore not thought to contribute significantly to quality
differentials in Australian centres. However, recent research by
Rush (2006) and previous research by Sims and colleagues (Sims,
2002, 2003a; Sims, Hutchins & Dimovich 2002) does suggest that
there exists considerable variation in these variables, despite the
intent of the legislation in setting minimum standards. In this study
there were some structural features of the childcare environment
that still influenced quality. In particular, the number of trained
staff in each particular group appeared to contribute to increases in
caregiver stress levels but decreases in childrens stress (and by
implication improvements in childrens long-term outcomes). A
better staff/child ratio was identified as linked to better QIAS
ratings and this is supported by the recent research released by
Rush (2006, and in this volume).
Inclusion of children with different needs is often thought to be
particularly stressful for caregivers. In this study, caregivers had
higher stress levels if they had higher numbers of children with
disabilities in their care, however, inclusion of children from CALD
was associated with lower stress levels and better performance on
the QIAS. It is possible that there is something about delivering a
program for children from CALD that encourages caregivers to
think about quality practice, reflect on their own practice, and thus
become better caregivers. Observing and reflecting on their own
practice may help them feel better about the service they are
delivering and thus lower their stress levels. Alternatively, it may be
that the inclusion support provided for children from CALD
231
backgrounds is particularly effective in improving practice and this
increases caregiver confidence and lowers stress levels.
The more experience caregivers have in child care and the
longer their employment in a particular centre, the more likely
caregivers were to deliver better quality care (as measured by lower
childrens stress levels and QIAS scores). Older caregivers
(presumably more likely to have been in the industry longer and to
have more experience) were more likely to be stressed. Despite
their higher stress levels, highly stressed caregivers were delivering
better quality care.
In the long term we know that more stressed workers are more
likely to burn out or to leave the industry. This preliminary study
suggests that the childcare profession in Australia is relying on a
stressed workforce to maintain quality standards. We know that the
childcare environment is one where caregivers are not supported,
not paid well and their work is undervalued. The high staff turnover
rates evidenced in the childcare industry today suggest that this is
not a good formula for long-term growth and development.
We need to prioritise a re-positioning of the childcare profession
to improve worker status. Improvements in status can then be
supported by improvements in training of workers, and
improvements in pay and conditions. When these changes are in
place we can expect significant improvements in child outcomes,
impacting on the future of Australias workforce and citizenry.
Without these changes we seem poised for a decline into chaos,
declining standards and increasing pressure on parental care to the
detriment of children, the workforce and society in general.
The childcare system of the future needs to be able to deliver
quality service to all children and families. In shaping this we
ought to be influenced by what has gone before, in particular the
community-based movement of the Hawke government in the 1980s
and the espoused intentions of the womens movement at that time.
We also need to consider the research from around
the world that demonstrates support delivered to parents makes
them feel effective and competent and makes a difference to
child outcomes.
We require a society that recognises the importance of the early
years, respects and values the role of parents and others who are key
232
people in the lives of young children, and provides the necessary
support so that every young child gets the best quality care in
whatever environment that child happens to participate. Where a
parent chooses to stay home with the child there ought to be state
funded support to ensure that the parent is supported to deliver the
highest possible quality care. If the parent chooses to return to work
that support ought to be offered to the alternative caregiver(s)
whether that be an unpaid family member or friend or a paid
caregiver in a formal care setting.
Child care should be defined to include the full range of services
from supporting parents in the home to providing out-of-home
alternative care in a group setting. In my view, child care ought to
be government funded but delivered by local agencies that have the
best knowledge of local needs. Childcare centres are part of this
spectrum of family support, and should be sufficiently flexible to
offer care that reaches beyond simply accepting a child in the
morning and returning that child to parents at the end of the day.
In this system, staff in childcare centres ought to function as
extended family members, providing advice and support, modelling
child rearing strategies, and offering parents opportunities to make
contact with other parents who live locally in order to develop their
own informal support networks. In this way, childcare centres can
offer opportunities for building on community strengths by offering
appropriate opportunities for parent education, and parent
advocacy. Childcare centres in this way operate as a community
hub. We know that parents are much more likely to direct their
energy and effort into issues relating to the wellbeing of their
children, and a high quality childcare centre can capitalise on that
to build community strength and capacity.
In order for this to be possible, funding for support must be
budget-based so that each local agency can best determine the
range of support services required in their community and contract
to deliver these services. In this vision, centres need to be
accountable to their local area and will have a contract to
deliver needs-based services relevant to their local community.
These can be evaluated on their effectiveness against their
local targets. Services will look very different from one area to
another as each is developed in response to local need and is
sufficiently flexible to change as local need changes. Thus child
233
care in its broadest sense becomes a holistic community response
to supporting young children and their families, and childcare
centres play a role in providing alternative care when this is an
identified community need.
Staff working in child care in this broadest sense need not only
to have child-centred expertise but must also have expertise in
working with parents, community development, empowerment and
an understanding of strengths-based practice. Staff must be highly
valued and their conditions of employment must reflect the high
value placed on their work. In an ideal context, staff will remain in
their positions for considerable periods of time and thus develop an
in-depth understanding of the community in which they work,
develop strong relationships with community members and
effective networks with others working in the community. Such
relationships and networks must be valued as a core component of
their work in the community.
In this vision, child care is about empowering parents and
communities to ensure that every child has the best possible
experiences in his/her early years of life.
234
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