Working Toward a Healthier Camp: Five Strategies for Camp Administrators to (Re)Consider Now!

Linda Ebner Erceg, R.N., M.S., P.H.N.; and Barry A. Garst, Ph.D.
The Healthy Camp Study has been completed. As a result, the camp community now has an initial understanding of camp injury/illness events founded on evidence. This understanding is already making an important difference in the quest to make camp an even healthier experience. The good news is that, based on data, camp is as safe as or safer than many other youth activities (see Table 1). Attention to risk management, thorough staff training coupled with effective supervision, and rigorous incident analysis all contribute to improving a given camp's risk profile. But there are also strategies that, if implemented prior to the start of a camp season, have the potential for even greater impact.
 
This article highlights five strategies, based on data from the Healthy Camp Study, that camp administrators should include in health and safety planning before camp begins.
  1. Incorporate illness prevention messages into parent and staff communications.
  2. Teach appropriate cough and sneeze etiquette.
  3. Develop and enforce footwear policies.
  4. Improve the use of protective equipment.
  5. Strengthen strategies that promote effective self-care among staff.
 
Although these strategies are not entirely new, data from the Healthy Camp Study indicate that many camps are not consistently implementing these simple steps. Nearly 200 day and resident camps have successfully integrated these strategies into positive changes in practice through their involvement in the Healthy Camp Study. As you read more about each of the following strategies, consider how your camp's health care practices could be improved.
 

Five Injury/Illness Strategies for Camp Planning Today

STRATEGY #1: Incorporate Illness Prevention Messages into Parent and Staff Communications

Staff and campers are twice as likely to have an illness that takes them away from their usual camp routine than they are to have an injury that does the same. It's time for camp administrators to focus as much on illness as they often do on injury. Illness robs campers and staff of time they would have otherwise spent in activities, the very thing they signed up to do at camp. Illness, especially communicable illness, also has the potential to quickly sap the energy of an otherwise positive camp experience. What can camp administrators do before camp begins to make illness less impactful?
 
Healthy Camp Study data indicated that a camp can expect that 5–7 percent of illness that occurs at camp will have started before the camper or staff member arrives. To increase the likelihood that people arrive in good health, embed health messages in parent communications and staff expectations/ policies (See "Resources for Injury and Illness Prevention"). Discuss the need for both campers and staff to arrive at camp ready for their camp experience. Whether participating as a camper or staff member, this means arriving with essential reserves in place: well-rested, well-nourished, and well-hydrated. These three attributes play a significant role in a person's ability to resist disease. Remove or weaken any one of them and a person becomes more susceptible to illness. Include these points in your camper and staff pre-arrival communications.
 
Use pre-arrival communication, such as e-mails to parents, to set forth the expectation that each person arrives ready to fully participate in their camp program. That being said, it's important to recognize that we're dealing with humans. There are times when someone may feel "under the weather." Should this occur during pre-camp days, especially the twenty-four to forty-eight hours before arrival, direct the individual to contact an appropriate camp administrator or camp health care staff, someone who can help make a decision about arrival or a delayed start. This may be as simple as being fever-free for twenty-four hours before coming to camp, or it may involve other steps such as having a physician determine if the individual is capable of full participation in their camp role. Regardless, the key message remains consistent: Campers and staff should arrive ready to participate in their camp program. Keep illness away from the camp gate.
 
The results of the Healthy Camp Study indicated that about 20 percent of reported illness was experienced by campers and staff whose illness was related to their pre-existing chronic medical condition. This suggests that: (a) the chronic condition stressed the individual's health, thus making them more susceptible to illness; and/or (b) the chronic condition made it more likely that the person would get an illness associated to the chronic condition (e.g., camper with allergies was more likely to develop a common cold or sinusitis triggered by a flare up of the chronic health condition). As a consequence of knowing about this tendency, camp administrators should augment staff training, particularly for those staff living and interacting with campers with a pre-existing chronic medical condition on a daily basis. Discuss the necessity for staff to help campers with chronic health concerns maintain their resilience (e.g., get adequate sleep) and refer these campers to the health center for assessment when they first mention minor symptoms. Consider a camp policy requiring that signs of illness are reported early, before they get worse, especially among those with pre-existing chronic health concerns.
 

STRATEGY #2: Teach Appropriate Cough and Sneeze Etiquette

About 50 percent of reported illness in the Healthy Camp Study was communicable — in other words, capable of being passed from person to person. The camp community's experience with influenza-like illness (H1N1) in the summer of 2009 aptly demonstrated the need for camps to be adequately prepared to attend to communicable disease control strategies. Conveniently, strategies that worked well for controlling H1N1 also apply for controlling more routine communicable conditions such as the common cold, strep throat, and infectious conjunctivitis.
 
A key to controlling a communicable disease is management of the airborne droplets that transmit microorganisms, which are passed from person to person via coughs and sneezes. First, an infected person coughs or sneezes into the environment, then a non-infected (susceptible) individual inhales the contaminated droplets, and voila, illness results. Or, perhaps, the contaminated droplets adhere to inanimate objects like doorknobs, phones, and keyboards. A non-infected person then comes in contact with the contaminated surface, and assuming a sufficient quantity of the causative organism remains, transfers the droplet to their mouth or nose. Again, illness is the result.
 
Any strategy that breaks the cycle of droplet transmission will impact communicability. One of these protective strategies is appropriate cough/sneeze etiquette, in which people bury sneezes and coughs in their shoulder/sleeve rather than covering the cough or sneeze with one's hands (see "Resources for Injury and Illness Prevention"). People do a lot with their hands: pass bread to the next person, use keyboards to obtain information, shake hands in greeting, turn on light switches, drink water from a fountain, and so forth. If a person has used that hand to cover a cough or sneeze, infectious droplets are deposited on various surfaces and potentially pass to the next person.
 
As camps coping with H1N1 learned, merely coughing/sneezing into one's shoulder minimized the potential for microorganisms to become airborne. Instead, the droplets were deposited on a surface (the shoulder) less likely to inadvertently contaminate others. This protective behavior must become "routine" at camp. Consider how your camp teaches staff about health protective behaviors. Is this already a component of your staff orientation and training program? Add cough and sneeze etiquette to this list, but more importantly, consider how the behavior is actually put into practice. It's not sufficient to simply know about this; one has to do it. Is your staff trained to model appropriate sneezing techniques for campers? Figure out a way to make effective cough/sneeze etiquette a given at camp, then couple this behavior with two other strategies to ratchet up the impact: effective hand washing and keeping hands away from the face.

 

STRATEGY #3: Develop and Enforce Footwear Policies

Earlier in this article you learned that campers and staff were twice more likely to experience an impactful illness than an injury. This is certainly interesting, but when injury data were examined, it was noted that trips, slips, and falls accounted for about 40 percent of injuries to both day and resident campers and staff. A significant factor in trip and fall incidents was whether or not the injured camper or staff member was wearing footwear appropriate to the camp activity.
 
Since data was collected during summer months, the use of sandals, flip-flops, and other less protective footwear were closely examined. What's the best approach? It appears that a couple of different approaches can be effective. While some camps reported out-right prohibition of flip-flops as an effective strategy, other camps talked about assessing camp activities and the environments in which activities occurred to determine what footwear was appropriate. Camp administrators should evaluate camp activities, as well as their own history of foot, ankle, and toe injuries, to make a determination of proper footwear policies and expectations.
 
An important step in implementing new footwear policies and expectations involves informing parents, because a new footwear policy might require you to revise your camp packing list to include descriptors of appropriate footwear. When so doing, consider factors such as shoes with both closed heel and toe areas, shoes with protected toe areas but open heels, and places where no shoes may be needed. Also consider activities that may require specialized footwear such as immersible shoes for aquatic programs, or targeted foot protection for equine/horsemanship programs.
 
Addressing staff footwear policies and expectations is critical because it's often most difficult to change the behaviors of staff. Furthermore, the footwear needs of staff might vary. Program staff leading group games or sports on the recreation field might need to wear closed-toed sneakers. Workers in the kitchen need footwear that remains functional on wet and/or slippery surfaces, covers the foot to protect against splashes from hot foods, and provides adequate support to ankles and arches as employees spend time on their feet. Some maintenance assignments may require steel-toed boots. And trip and travel staff members need footwear that complements the trip's environment. Communicate your camp's footwear policies and expectations during the hiring process, verify that the employee is appropriately prepared upon arrival, and then evaluate the employee's ability to follow safety policies regarding footwear during their performance review process.
 
Whether working with employees or campers, camp administrators are encouraged to predetermine their response should an individual have inadequate (i.e., unsafe) footwear. In most states, it is the responsibility of employers to inform a prospective employee about necessary work attire; it is the employee's responsibility to report to work with the necessary attire. Management's response to campers with inadequate footwear may be different from that used for employees. The response might range from not allowing the camper to participate in a specific camp activity to purchasing the needed footwear and billing the appropriate account. There can be a number of solutions for both campers and staff. The point is to plan ahead and have predetermined options should an individual not comply with footwear policies and expectations.
 

STRATEGY #4: Improve the Use of Protective Equipment

As reflected in Table 1, the rate of injuries in day and resident camps was very low. But when injuries did occur, data from the Healthy Camp Study revealed that campers and staff were often not using protective equipment. Although provided by the camp, protective equipment was sometimes ignored, or the equipment itself was inadequate (e.g., wrong size, needed repair). As a result, when injuries did occur, they were often more severe because of the lack of the use of protective equipment. Because over 50 percent of impactful injuries for both day and resident campers occurred during camp activities which often have protective equipment associated with them, this becomes an important opportunity for prevention.
 
Motivating campers and staff to consistently use protective equipment may require changing camp culture. It should be a given — a rule — that protective equipment, when available, is used. Consider a no tolerance policy regarding protective gear, whether that is wearing a lifejacket, using a glove to protect against cuts while on kitchen duty, or wearing an appropriately sized helmet. Such a policy, however, may be easier said than done. Change theorists describe how time is needed to effect change, so set reasonable goals and start today!
 
Camp administrators may be able to clarify their stance regarding protective equipment when pushed to identify the areas for which such a policy truly makes a difference. In some situations, protective equipment may mean the difference between life and death. Wearing a lifejacket is an example of this. In other situations, protective equipment prevents major injury, as illustrated by the fall protection maintenance personnel utilized when working at significant height, or the use of helmets when horseback riding or participating on a high ropes course. But other protective equipment — like the arm guard in archery — may only prevent minor injury (e.g., bruising). Upon reflection, camp administrators may identify circumstances for which protective equipment is required and those situations in which use is preferred. Camp administrators should assess what protective equipment will be provided by the camp based on camp activities and then determine if the use of protection by campers and/or staff is required or preferred. Communicate those decisions — and the rationale for them — to campers and staff. This helps people understand the "why" behind decisions and increases the likelihood that such policies will be followed.
 
Note that this discussion started by noting two reasons for non-use of protective equipment. The second reason — lack of appropriately sized equipment and/or equipment in poor repair — reveals more about camp management than it does about a given camper or staff member. Consider the directives given to staff about equipment maintenance and adjust them to address both aspects for non-use of protective equipment. Does last summer's end-of-season inventory include comment about needed repairs or new purchases? If so, have those repairs been made? Has new equipment been ordered? If not, add the topic to the inventory form. Do pre-season readiness checks direct staff to complete repairs in a timely manner? And how is equipment repair tracked once camp is in session? Who's responsible and who's accountable for such repairs?
 
With regard to appropriately sized equipment, do end-of-season reports submitted by program staff address this issue? Do management practices address phased replacement of protective equipment so costs are distributed over time? Is there need to increase the number of a particular type of protective equipment because of changes in the camper profile (e.g., more younger campers, fewer older campers)? Might updates in the technology surrounding protective equipment drive the need to replace out-of-date items? Camp administrators should periodically review management practices and update those that may be restraining factors to the camp's practices surrounding use of protective equipment.
 

STRATEGY #5: Strengthen Strategies that Promote Effective Self-Care among Staff

The differences between campers and staff are important to note when considering injury and illness prevention strategies. Campers are clients; they are cared for in a way that supports business continuance (e.g., provide a safe environment and positive experience, encourages them to return for another camp season, etc.). Staff members are employees; they are hired because each has a skill set needed for a particular camp position. They are cared for and supported in an effort to maintain their ability to do their jobs.
 
But camps also have an interest in youth development and recognize that most staff members are actually older adolescents who need fairly consistent coaching about job expectations, performance, and personal development. Consequently, camps tend to "take care of" their staff, albeit in a different way than they care for campers. This distinction in care taking, however, is often not articulated by camp administrators nor discussed with staff. Consequently, the potential for mixed messages exists. It's time to change that.
 
How can camp administrators teach staff to take care of themselves? Might some practices be changed to more clearly communicate this message? For example, do staff complete a health history form that is employee (work) oriented, or are they handed the camper form and told to fill that out? By providing a health form that focuses health in terms of ability to do a job, one communicates that staff are not campers. The focus of their health maintenance is couched in continued ability to do what they were hired to do. Giving staff the same form used by campers misses this point — and opportunity — entirely.
 
Does staff orientation and training include a discussion about the distinctions between camper and staff roles in a way that places emphasis on self-care for staff? This conversation may be most valuable if first implemented with staff leadership, thus providing them the opportunity to articulate the distinctions, clarify various points, and improve their ability to facilitate discussion with the rest of the staff.
 
Perhaps one of the greater tension points in staff health exists around the perception and management of staff fatigue. Many camp professionals can testify to the difference between staff energy at the start of camp as opposed to four or five weeks into the season. The staff fatigue factor often shows in demeanor and emotional resilience long before it shows in other ways. The ubiquitous adage, "get more sleep," begins to surface more and more as the season wears on. And what happens to camper supervision as staff members become fatigued? Older adolescents (i.e., most of your camp staff) are developmentally hardwired to push boundaries to determine their personal limits. Might there be a dilemma when we put them into camper supervision positions and ask them to care for younger children? This is an interesting point, especially with regard to maintaining personal energy levels so as to remain capable of both completing tasks as well as supervising campers.
 
The Healthy Camp Study examined the impact of fatigue on injury and illness rates. Camps were asked to respond to the question, "Did fatigue play a role in this injury/illness incident?" The answer was a resounding "Yes" in about 40 percent of the cases. That percent rose when applied to staff injuries and illnesses, especially those that occurred as the summer wore on. Knowing this in addition to the fact that the older adolescent — by virtue of developmental task — is supposed to push his/her proverbial envelope, how might a camp administrator respond? Bringing the verve and energy of staff members who are older adolescents to camp is desirable, yet what can be done to minimize the potential that a given staff member's natural inclination to strive toward meeting development tasks will not result in an overly fatigued individual?
 
The answer lies in strategies that address appropriate self-care. Camp administrators should evaluate how they coach their employees to identify the ways in which self-care is currently taught, as well as areas that may benefit from improvement. For example, staff may be admonished to "get more sleep," yet few performance appraisal tools include statements such as "How well does this employee manage his/her personal needs so he/she remains capable of doing his/her job?" By linking verbal coaching of a skill to evaluative techniques, one captures desired behaviors in a way that makes them more likely to occur. It also sets the stage for a head-on discussion with staff on the topic, should the desired behavior not exist or need improvement. Strategies like this link a supervisor's coaching of self-care with the employee's responsibility for the behavior, thus enhancing the potential for the desired outcome: well-rested staff.
 

Take the Pulse of Your Camp's Health Practices

While the Healthy Camp Study focused on the injury/illness experiences of day and resident campers and staff, information gleaned from that research also indicated opportunities for prevention. This article targeted five simple strategies for camp administrators to consider prior to the start of camp. Consider the list of strategies below as a checklist for your camp. How would you do? Where can you improve your practices? This is an opportunity for self-reflection followed by refinement of program policies.
  • Maximize the potential for illness prevention by utilizing pre-arrival messages.
  • Articulate and enforce effective camp footwear policies/expectations.
  • Develop strategies to assure that effective cough/sneeze techniques are used.
  • Strengthen practices surrounding the use of protective equipment.
  • Promote effective self-care among staff.
 
Efforts in these areas should reap important benefits during the camp season, with the most important benefit being more campers and staff engaged in the camp experience, and less time spent in the health center or in transportation to emergency care.
 
The Healthy Camp Study, a five-year monitoring study of injuries and illnesses in day and resident camps, was sponsored by Markel Insurance Company.
 
Linda Ebner Erceg, R.N., M.S., P.H.N., is the associate director of Health & Risk Management for Concordia Language Villages and executive director of the Association of Camp Nurses in Bemidji, Minnesota.
 
Barry A. Garst, Ph.D., is director of program development and research application for the American Camp Association and adjunct faculty at Virginia Tech. He can be contacted at bgarst@ACAcamps.org.
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