Health Planning Project II: Noah s Ark Rebecca Cominoli ... · Health Planning Project II: Noah’s Ark Noah’s Ark Christian Day School is located in Mason Memorial Church and provides

Running head: HEALTH PLANNING PROJECT 1

Health Planning Project II: Noah’s Ark

Rebecca Cominoli, Bree Davis, Jennifer Geer, Kelly Jansen, Faith Kim, Cortney O’Connors,

Jennifer Smith, Julie Teegarden, and Alexis Tynes

Old Dominion University

HEALTH PLANNING PROJECT 2

Health Planning Project II: Noah’s Ark

Noah’s Ark Christian Day School is located in Mason Memorial Church and provides

daycare and preschool services for the residents of Norfolk, Virginia. It provides care and

education for children ages 6 weeks to 5 years old as well as before and after school care for

children up to age 12. The majority of families that use this facility receive financial assistance

through the Virginia Department of Social Services and the Norfolk Planning Council in order to

pay for the service. Throughout the Fall 2014 semester, students from Old Dominion

University’s (ODU) School of Nursing have developed a relationship with the staff and children

of Noah’s Ark in order to assess the needs of this community. The data gathered during this

assessment period led to the formation of the priority nursing diagnosis of deficient knowledge

related to disease transmission, personal hygiene, and handwashing techniques. This diagnosis

has formed the basis of the continuation of the Health Planning Project at Noah’s Ark and the

interventions implemented by the students. This paper will illustrate how the Health Planning

Model was used to apply the nursing process in order to assist this aggregate with improving

their health. It will describe the nursing diagnosis, goals, interventions, implementation,

supporting research, barriers, evaluation, limitations, recommendations, and implications of this

project.

Planning

Nursing Diagnosis

The nursing students spent a collective total of 540 hours at Noah’s Ark over two

semesters from October 2014 through April 2015. During these hours the students assisted with

the care of approximately 20 children between the ages of 6 months and 5 years of age. This

allowed the students to observe the staff of Noah’s Ark unobtrusively and led to the priority


nursing diagnosis of Deficient Knowledge related to disease transmission, personal hygiene, and

handwashing techniques as evidenced by staff and children not washing their hands following

the protocol recommended by the Centers for Disease Control and Prevention (CDC) or as often

as required by the Virginia guidelines (CDC, 2013; Commonwealth of Virginia Department of

Social Services [CVDSS], 2012). During the initial assessment period in Fall 2014, the students

estimated that the staff washed their hands less than 10% of the number of times that they should

have if they had followed the Virginia guidelines. According to the Virginia guidelines, there

are specific times when staff are required to wash their hands including, but not limited to, before

feeding or helping children with feeding, after contact with body fluids, after diapering a child,

and after assisting a child with toileting. It also states that if running water is not available, then

disposable wipes are to be used to clean hands (CVDSS, 2012). During the seven months

working with Noah’s Ark, students observed the staff not washing their hands during the

activities previously mentioned as well as not using disposable wipes to clean the children’s

hands during their outdoor playtime when they were without access to running water. Students

noticed that staff would wipe the runny nose of one child and not wash their hands before wiping

the runny nose of another child. Students also noted staff would use the same tissue for multiple

children.

In addition to the diagnosis of Deficient Knowledge, the nursing diagnosis Readiness for

Enhanced Knowledge related to communicable disease transmission and prevention as evidenced

by aggregate actively participating in the presentation about communicable diseases by asking

and answering questions and by staff members requesting additional information from students

applies to this aggregate. Throughout the time the nursing students spent at Noah’s Ark, certain

staff members showed an interest in learning more about how to protect the health of the


children. Additional information was requested regarding best practices for cleaning toys,

recommended bleach concentrations, and solid surface disinfection. Staff also questioned the

center’s use of watered down soap and asked students to bring in more information about how

that can negatively impact health.

The nursing diagnosis that follows closely behind is Risk for Injury related to an increase

from 10-12 children daily from the fall semester to at least 15-17 daily this spring semester

without an increase in staff. According to the Virginia Daycare Standards, there should be one

staff member to five children between the ages of 16 months and two years old, one staff

member for every eight children for two year olds, and one staff member for every 10 children

between the ages of three and five years old (CVDSS, 2012). There have been several occasions

where Noah’s Ark exceeded those ratios putting not only the children at risk but also the daycare

as a whole. This is a new diagnosis and was not identified during the fall semester but became

apparent during the spring 2015 semester.

Goals and Objectives

Throughout the year at Noah’s Ark, transmission of infection between children and to the

staff remained a continuing problem. It is estimated that nearly half of the children in attendance

each day were sick. The facility has struggled with staff reliability and retention, which has

increased throughout the last half of the year, with illness-induced absences adding to the burden.

Furthermore, poor hygiene practices exhibited by the staff, such as failure to wash hands before

serving food or after wiping a child’s nose, were consistently observed. Due to these

observations, an intervention was deemed necessary. The ultimate goal of the intervention was

to decrease the spread of infection at Noah’s Ark by educating the staff on common


communicable diseases, ways they are spread, and how to prevent transmission, with a focus on

hand hygiene.

The nursing students applied two specific, measurable objectives to the plan of action.

The primary objective was to focus on education of the five full-time staff members by

administering a pretest followed by a 30-minute teaching, a posttest, and finally, another test one

month later to identify retention rates. The three tests were identical in order to conduct an

accurate comparison of staff content absorption and retention, both before and after the

intervention. The short-term desired outcome was that, following the teaching intervention, all

full-time staff members would be able to answer at least 80% of the questions on the posttest

correctly. The long-term desired outcome was that, one month later, all five full-time staff

members would still be able to answer at least 80% of the questions on the posttest correctly.

The secondary objective focus was to reemphasize hand hygiene with both the staff and students.

Nursing students collected data by observing the handwashing patterns of the staff and students

before and after the teaching to identify any change in their practices. The desired behavioral

outcome for this secondary intervention was that following the teaching intervention, staff

members would exhibit hand hygiene habits which followed protocol stipulated in the Virginia

Standards for Licensed Child Day Centers (2012) at least 80% of the time.

Intervention

Implementation

The primary intervention was a teaching session with the full-time staff members of the

daycare (see Appendix for teaching plan). This was implemented to educate the staff on common

communicable diseases and the importance of hand hygiene as the basis for preventing the

spread of communicable diseases between children and caregivers. The teaching about common


communicable diseases provided information to help the teachers identify characteristics of

certain diseases that the children in the daycare were at the greatest risk for catching. The goal

was to educate the staff enough for them to be able to take appropriate actions to prevent the

spread of these common diseases when a child arrived at the daycare with specific signs and

symptoms. This was done by creating a teaching plan that was designed following current CDC

recommendations. The teaching was conducted in a half-hour, took place at the daycare facility,

and utilized a one-to-one nursing student to staff ratio. A poster-board was designed as an

additional visual aid during the presentation.

The secondary intervention was to provide Noah’s Ark with five disease reference

binders containing handouts written by the students. These handouts indicated what each disease

was, how it was spread, if the child should go home, how long they should be out of daycare, and

what to teach the parents. The diseases covered during the teaching presentation were Norovirus,

Influenza, Ringworm, Strep throat, and Respiratory Syncytial Virus; however, a total of 24

diseases and conditions common to this aggregate were included in the binder. The five main

diseases, and several others that were common in the preschool population according to the

CDC, were flagged within the binder for easy access. The binders were written using language

that was deemed readable at a fifth grade level. This increases comprehension of material and

has been shown to increase compliance because the material is at a readable level (Ryan et al.,

2014).

Alternative Interventions

Alternative interventions that were used to help decrease the spread of infection included

fundraising undertakings to supplement hygiene supplies at Noah’s Ark. It was thought that if

the supply of hygiene products increased, then hygiene care would increase. The nursing


students observed that basic hygiene supplies were missing; examples noted were watered down

soap, no paper towels available, no gloves available, and no extra diapers. It was thought that the

cause of this limited hygiene use was related to limited funds. The following interventions were

devised in providing better hygiene: a crowd-source funding website for monetary donations,

donation boxes in key areas of the ODU Health Sciences building, and offers of extra credit for

students who donated. A fourth intervention, door-front solicitation at a local Wal-Mart, was

unsuccessful because the students were unable to obtain permission. Overall these secondary

interventions to increase the hygiene supplies were very successful.

Crowd-source funding. A Gofundme page was created to bring in money to buy

supplies for the aggregate. Gofundme is a crowdfunding platform that allows people to raise

money through a personalized website that can be shared through social media and e-mail. The

nursing students tailored a campaign to appeal to the emotional side of the audience by

emphasizing the needs of the children. Most of the money donated came from friends and family

members affiliated with the nursing students. The Gofundme page was very successful as the

nursing students were able to raise $385. With the donated money, the nursing students bought

1000 gloves, two bulk sets of paper towels, ten gallons of antibacterial hand soap, three gallons

of bleach, 3000 baby wipes, and three sets of baby diapers. These items were selected due to

their high daily usage in the daycare. Soap and paper towels were especially important because

students observed the staff stretching resources by watering down soap or cutting paper towels

into small, impractical pieces. This money was also used to buy paper cups, paper bowls, and

plastic spoons, as the students observed these one-time use items collected to be reused at a later

time.


Donation boxes. To heighten awareness within the community of the needs of Noah’s

Ark and to help bring in more supplies, the nursing students set up donation boxes in the ODU

Health Sciences building. The student body of ODU was targeted because of its vast population.

Fliers were hung around the campus and shared on the ODU School of Nursing Facebook page

to market the need for donations of soap, paper towels, baby wipes, and disposable gloves. The

boxes were available from the beginning of February to the end of April. The success of the

donation boxes was minimal; donations made from outside of the School of Nursing

accumulated to five items. The lack of success of this intervention may have been due to

inconvenience of the targeted audience or poor advertisement.

Student extra credit incentives. To help with providing supplies, the nursing students

asked a professor at the university to offer an extra credit incentive for donations. The university

students had five weeks to provide donations under this incentive program. Out of 32 students,

24 donated for extra credit. The donations included paper towels, baby wipes, soap, and one box

of disposable gloves. The extra credit incentive was very successful as the donations tallied up to

over 70 items.

Retail solicitation. The nursing students also attempted to increase the target population

by scheduling a door front donation at Wal-Mart. The goal was to ask incoming customers to

donate to the aggregate by buying supplies while in the store and dropping off purchased goods

on the way out. The nursing students contacted the management at Wal-Mart many times;

however, they were unable to arrange a date for the proposed drive. In the end, this intervention

was not needed because of the success of other interventions. With the success of the Gofundme

page and the extra credit incentive a grand total was collected of: 61 rolls of paper towels, 272


plastic bowls, 552 paper cups, 20 gallons of antibacterial soap, 3 gallons of bleach, 1000 gloves,

3000 baby wipes, 600 plastic spoons, 20 tissue boxes, 5 books and 3 sets of baby diapers.

Supporting Research

Common communicable disease. Communicable diseases run rampant in the daycare

setting and have a negative impact on the overall health of children (Wagner & Clodfelter,

2014). At Noah’s Ark, the nursing students observed that 30 to 50% of the children exhibited

frequent symptoms of illness throughout the past year. Signs of illness which were observed

included runny noses, ear pulling which may indicate pain, and diarrhea. This is consistent with

the results of Morrissey (2013), which found that greater numbers of children enrolled in the

classroom correlated with higher rates of respiratory, ear, and gastrointestinal infections. The

high rate of infection at Noah’s Ark was related to both the observed deficient knowledge of the

staff and the high child to teacher ratios. High child to teacher ratios impair the teacher’s ability

to perform necessary interventions to prevent the spread of infection; examples include

handwashing, disinfecting surfaces, and teaching children cough etiquette (Morrissey, 2013;

Wong, Cheng & Lo, 2010).

Disease education. To address the primary nursing diagnosis of deficient knowledge

related to disease transmission and hygiene practices, the nursing students educated the staff on

the most common diseases observed in this preschool. Additional information was included

regarding the method of transmission, common signs and symptoms of the disease, when or if

the child should go home, treatment, and when they can return to the school. Wagner and

Clodfelter (2014) utilized similar teaching to what was implemented at Noah’s Ark which

included information regarding the prevention of outbreaks, understanding the illnesses, and

interventions administrators should immediately take. They found that education played a


significant role in reducing the number and severity of disease outbreaks. With this information

in mind, the nursing students hypothesized that providing additional disease education to the

teaching staff would enhance their knowledge and ability to implement health practices within

the facility on a day-to-day basis.

Education reading level. Wagner and Clodfelter (2014) suggest that knowledge of

communicable diseases is an important part of reducing communicable illness transmission in

daycare settings. They recommend both assessment of the baseline staff knowledge and focused

staff training regarding transmission and prevention of communicable diseases in order to

improve the health status of children. Therefore, the nursing students focused on the education

of Noah’s Ark teaching staff in order to best enhance the overall health in the facility. To ensure

the comprehension of materials presented during the teaching, the nursing students provided all

materials at a fifth grade reading level according to the recommendations of Ryan et al. (2014).

Additionally, the nursing students supplemented staff knowledge gained through the teaching

session by providing an educational disease binder with 24 common communicable diseases in

the preschool age group. The disease binder was written using plain language to support

comprehension based on the educational level of the teaching staff, which allowed the binder to

be more accessible to those seeking more information.

Handwashing. The nursing students also worked with the aggregate to promote

handwashing based on recommendations from the previous community health group and the

understanding that hand hygiene is the most effective mechanism of infection prevention and

education is the most effective means of promoting change (Weese & Weese, 2011; CDC, 2013).

Therefore, the nursing students provided education regarding hand hygiene technique and

timing. Additionally, they assisted the children in performing handwashing following


recommendations from Weese and Weese (2011), who suggested that younger children benefit

from mandatory hand hygiene under teacher supervision. The nursing students also assessed the

environmental barriers preventing appropriate handwashing practices and found that limited

availability or absence of paper towels, poor quality soap, and trying to conserve water as a

means to limit financial costs all had an impact. The observed environmental barriers in this

preschool setting were similar to the barriers Rosen et al. (2011) found which included limited

liquid soap or the use of bar soap, absence of soap dispensers, lack of paper towels and paper

towel dispensers, and use of cloth towels for hand drying. To reduce the environmental barriers

at Noah’s Ark, the nursing students supplied the school with necessary supplies to perform hand

hygiene including soap and paper towels. Although environmental factors such as soap and paper

towels improve handwashing frequency, an educational component is required in order to change

the behavior and attitude of staff (Rosen et al., 2011). Thus nursing students provided Noah’s

Ark with the necessary supplies for and the proper education on hand hygiene practices with the

goal of improving the overall health status of the facility. They also provided education on the

ineffectiveness of watered down soap with the goal of discouraging this practice in the school

setting.

Barriers to Intervention

The nursing students encountered many barriers while carrying out interventions for

Noah’s Ark. One consistent problem identified was a profound lack of resources. In addition to

not having the resources available to make good hygiene possible, there were staff shortages,

high staff turnover at the facility, and difficulty bridging the perceived needs of the director with

those of the nursing students. These difficulties were encountered not only on the day of the

intervention, but also while the nursing students were trying to determine the best use of their


limited time with Noah’s Ark. Finally, the weather also worked against the students during a

very snowy spring semester.

Staffing shortages. Staffing shortages were one of the greatest barriers nursing students

faced when interacting with Noah’s Ark. When the nursing students arrived for their assigned

shifts, classrooms frequently contained more children than allowed by the Commonwealth of

Virginia Department of Social Services (2012). For example, one Noah’s Ark teacher was

observed caring for 14 children between the ages of two and four years old in one classroom,

which is outside of the mandated ratios of one teacher per eight children for two year olds and

one teacher per 10 children between three years and entry into school (Commonwealth of

Virginia Department of Social Services, 2012). Due to the paramount need for extra hands in the

classroom, the preschool director tasked the nursing students with helping teachers provide

hands-on care for the children of Noah’s Ark. This assignment made it difficult for the nursing

students to fulfill their own assessment-driven goals for Noah’s Ark.

Staffing was also of particular concern at the time of the teaching intervention. That day,

there were only four main staff members and the director of Noah’s Ark caring for more than 20

children aged from infancy to four years old. This was problematic in that the group chose to

focus the intervention on the staff members in a one-on-one teaching session. During this

session, staff members had to be removed from their posts in which they were directly watching

over the children to instead participate in the teaching intervention. The group overcame this

barrier by planning the intervention for a day in which more students were available to

participate, so that at least two students could replace each staff member during the intervention.

Staff retention. Staffing was also a concern in that there has not been a consistent group

of staff throughout the year. There were a few staff members who returned each week to the


daycare, but many nursing students observed a constant stream of new faces in its classrooms.

The frequent turnover had a negative effect on relationship-building with Noah’s Ark due to the

time required to establish rapport between students and staff. This may also have contributed to

the attitudes of some of the children at Noah’s Ark who often demonstrated defiance towards the

teachers when polite requests were made.

Staff retention was also a concern when planning the intervention because the students

did not know how many or which staff members would be present. In addition, this fluctuation in

staffing made the intervention’s success more difficult to evaluate. It was a concern that the staff

members who were present for the teaching intervention would not be present for the long term

re-evaluation. While the students were able to re-evaluate all of the staff who participated, one of

those staff members has recently resigned from her position, thus limiting the long-term success

of the intervention.

Conflicting interests. Another barrier that the group faced was resistance from the

director. Because the director was concerned about the lack of extra staff members on the day of

the intervention, she attempted to limit the one-on-one teaching session duration. The director

was informed prior to the intervention that extra nursing students would be available to help in

the classrooms while teachers participated in the teaching session; however, she was reluctant to

allow staff to participate on the pre-determined day. In order to overcome this barrier, the group

re-emphasized the availability and willingness of the nursing students to cover the missing staff

member during the intervention. The group also compromised with the director to only utilize a

total of 30 minutes to complete the intervention with each staff member, increased from the 15

minutes desired by the director initially. In order to allow smooth operations throughout the


intervention period, the director was encouraged to choose the order in which each staff member

participated in the intervention.

In addition to having different views regarding the utilization of staff time, it was

apparent that the director had very different ideas as to how nursing students could best help her

organization. While many of the staff were very interested in receiving additional education

regarding hand hygiene and communicable diseases, the director was more focused on increasing

the amount of resources and toys for the children. In order to overcome this barrier, the group

worked toward accomplishing both needs. The group provided the teaching, raised funds, and

donated resources to the preschool which included needed baby wipes, paper towels, rubber

gloves, and antibacterial soap.

Inclement weather. A less significant barrier was the inclement weather in the area at

the time that the group was planning the intervention. The carefully planned intervention had to

be rescheduled due to a snowstorm that caused the daycare and most of the surrounding area to

close. Unfortunately, this meant that some of the students who originally were able to participate

had other school-related obligations that inhibited their direct participation in the intervention on

the rescheduled day. This barrier was overcome by coming together as a group to reassign tasks

so that all members contributed greatly to the intervention in their own way.

Evaluation

Evaluation Process

In order to evaluate the effectiveness of the teaching intervention at achieving the goal of

increasing the health knowledge of the staff related to hygiene, disease transmission, and

handwashing protocol, a two part assessment was used. The primary knowledge evaluation

method utilized a time series pretest and posttest design which allowed assessment of immediate


intervention results and retention one month after the intervention. Following this design allows

testing of cause and effect relationships and does not require a control group, but may suffer

from threats to internal validity and must be interpreted with caution (LoBiondo-Wood & Haber,

2010). It was chosen because it would allow assessment of whether there was an improvement

in knowledge following the intervention and because it was both inexpensive and rapid. The

secondary behavioral evaluation used unconcealed observation of staff member hand hygiene

behaviors by all students throughout the project period. This method was chosen because it was

an inexpensive and easy way to assess the behavioral impact of the intervention.

Primary Knowledge Evaluation

The expected outcome of the teaching intervention was that following a teaching session

on common communicable diseases and handwashing technique, each staff member would be

able to identify concerning symptoms, routes of transmission, and institution protocol for the

common communicable diseases as evidenced by answering at least 80% of a student-

administered posttest correctly. Additionally, the posttest was given again after one month in

order to assess the level of retention with the objective that all staff members would be able to

answer at least 80% of the student-administered posttest correctly. Both the materials used for

teaching the staff and the test were written by the students with consideration for the low

educational status of the Noah’s Ark community. As previously described, the majority families

of children attending Noah’s Ark have at or less than a high school education. Ryan et al. (2014)

report that most Americans read at or below the ninth grade level, and their study recommended

that printed health materials be written at the fifth grade level. Therefore, the test and all printed

materials supplied to Noah’s Ark were written in plain English at a lower reading level, except


when there was no other name for a particular illness, in order to increase staff comprehension

during the presentation and testing period.

Prior to beginning the teaching intervention, staff members were given the test in order to

establish a baseline knowledge level. One staff member was not present at the beginning of the

teaching session and therefore does not have a recorded baseline level. Of the other four staff

members, one knew 50% of the answers, one knew 60% of the answers, and two knew 80% of

the answers. After the teaching intervention, two staff members knew 90% of the answers, and

three knew 100% of the answers. These results met the initial intervention objective of all staff

members answering at least 80% of the questions correctly. This also meets the overall goal of

improving staff knowledge regarding personal hygiene, communicable diseases, and

handwashing protocol. One month after the teaching intervention, the staff members were given

the posttest again in order to assess retention of the information over time. At the one-month

retest, three staff members knew 90% of the answers and two staff members knew 100% of the

answers. This met the intervention objective that all of the staff members would continue to

have improved knowledge regarding personal hygiene, communicable diseases, and

handwashing protocol as seen by answering at least 80% of the test questions correctly.

Secondary Behavioral Evaluation

The secondary method of evaluation was an unconcealed, observational study of the staff

members’ hand hygiene practices during the month following the teaching intervention.

According to the Centers for Disease Control and Prevention (CDC), handwashing that uses

appropriate technique is the best method of preventing the spread of disease (CDC, 2013).

During the fall semester of 2014, students observed staff members neglecting to wash their hands

between tasks in which they were in contact with potential contaminants; these tasks included


wiping children’s noses and changing diapers. Proper hand hygiene requires that the staff

members wash their hands or change gloves between different children’s runny noses, between

changing different children’s diapers, to wash their hands at the end of the procedure, to wash

their hands after using the bathroom, and to wash their hands before handling food. However,

staff at this facility were observed to use the same gloves for multiple children and to not wash

their hands after wiping runny noses approximately 90% of the time. Therefore the objective

was that following the teaching intervention, staff members would exhibit hand hygiene habits

which followed protocol stipulated in the Virginia Standards for Licensed Child Day Centers

(2012) at least 80% of the time. In order to reduce individual bias, all of the students gathered

data independently and reported it to one student who combined it for this paper.

Each of the nine students observed the staff members of Noah’s Ark for a four-hour

period of time during the month following the teaching intervention. Students recorded the

number of times the staff washed their hands as compared to the number of times that the staff

should have washed their hands according to the Virginia Standards for Licensed Child Day

Centers (2012) protocol. These numbers were used to determine the percentage of time that the

protocol was followed. Three of the students did not observe the staff washing their hands at any

point during their observation period, other students recorded percentages as follows: 6, 17, 20,

25, 27, 33. Therefore the range was 0-33%, with an average of 14% compliance. This did not

meet the objective that the staff would exhibit hand hygiene habits which followed protocol at

least 80% of the time. Although the teaching intervention successfully increased the knowledge

of the staff regarding hand hygiene and common communicable diseases, this knowledge did not

translate into changes in their hand hygiene behavior.


Limitations

The primary limitation to this study was that there were only five full-time staff members

available on the day of the intervention, which did not represent all of the staff of Noah’s Ark;

other staff members who could have been included since they work directly with students

include part time teachers, the secretary, the cook, and the bus driver. Throughout the time spent

with the aggregate, the staff was in constant flux; staff members were not reliably present and

four teachers quit during the seven month period. This inconsistency limited the ability of the

students to determine who to teach and which day would include the greatest number of staff.

One of the staff members who was included in the teaching intervention has since resigned from

the facility.

Another limitation to this study was the short period of observation following the

teaching intervention. Because the intervention had to be planned and implemented, there was

only one month left in the semester following the teaching session and students were not able to

perform more than one observation each in order to count episodes of handwashing. An

increased period of observation following the teaching intervention would have allowed students

to collect more data. This shortened time period also prevented a longer term study of the

retention of the information presented in the teaching intervention. The second posttest should

have been repeated after three or six months in order to more accurately reflect retention of the

information. Finally, the students should have counted episodes of handwashing during the

previous semester in order to more accurately compare pre- and post-intervention data. Instead,

students used data which was estimated from observations made in the fall semester.


Recommendations

Due to the resignation of the Noah’s Ark staff member who was most receptive to health

education and hygiene promotion, Noah’s Ark may not be the best place for future nursing

students to try to implement positive changes. However, if Noah’s Ark is to be utilized as a

clinical site in the future, students will need to develop a very different tact to effectively

promote change within this aggregate. Future students working with Noah’s Ark would do well

to explore means of boosting morale and team-building, help Noah’s Ark better utilize their

existing financial resources, help them find other applicable resources, and widen education to

the parents of Noah’s Ark students.

Boosting Morale and Team-building

After the teaching intervention at Noah’s Ark, the nursing students found that the

fundamental problem at Noah’s Ark was not a knowledge deficit problem, but a morale and

resource problem. The staff at Noah’s Ark are in constant flux and frequently express their

frustration with the current operations at the daycare. As evidenced by the results of the

knowledge-based intervention, the staff are more than willing to learn and are capable of

retaining new information. However, staff are not emotionally able to fully apply the concepts

discussed and do not always have the resources available, such as readily accessible soap and

water, in order to act upon their new knowledge. It is perhaps in the best interest of the Noah’s

Ark teachers to have instruction in stress relief mechanisms so that they may better cope with the

demands of their work at Noah’s Ark. Future students should also work with the school director

directly to promote team-building and improve morale so that future interventions may prove

more successful.


Bolstering Existing Financial Resources

Future student groups may also assist Noah’s Ark to better utilize their existing financial

resources. Teaching couponing may aid in attaining the resources needed to operate the facility,

such as toilet paper, tissues, paper towels, diapers, wipes, and food. Forging closer financial ties

with Mason Memorial Church, which houses Noah’s Ark, may allow the preschool to support

itself more effectively. Financial advisement services could further this self-sufficiency by

providing instruction in effective use of their existing financial resources to meet their end goals.

Finding outside assistance. Another route students can take is spending clinical time finding

outside resources that may be able to help Noah’s Ark. Such resources may be financial, such as

state or federal funding programs to help with meals. Health resources could also be utilized by

establishing partnerships with dental hygiene facilities to ensure appropriate dental health for

students, or having the Well Child Clinic, associated with the City of Norfolk Public Health

Department, come talk to interested families. Working to establish a volunteer group based

within Mason Memorial Church to regularly assist teachers and administrators at the facility

would also be extremely beneficial due to frequent understaffing and the high turnover of current

staff. More detailed assessment of the school’s needs and goals by future nursing students may

provide a means of ascertaining further types of resources that would be beneficial to the

organization.

Providing Parents with Educational Opportunities

If the staff and children of Noah’s Ark are not to be the interventional targets, future

students may aim to improve the health of this aggregate by approaching the parents directly.

Parents are a child’s first teachers, and the nature of the relationship between a parent and child

sets the tone for the child’s future development; a warm, nurturing relationship and decreased


home stress provide for a child’s optimal development and ability to concentrate (Weiss, Caspe,

& Lopez, 2006). In addition, parental involvement in a child’s academic endeavors, including

fostering positive relationships with teachers, have correlated to better language, social, motor,

and adaptive skills, as well as fewer behavioral problems (Weiss et al., 2006). Incorporating

parent nights at the school, with dinner provided, which highlight topics the children are learning

in school and health topics, may serve to foster parent involvement in the school. Further parent

involvement could then lead to better academic and behavioral outcomes for the students of

Noah’s Ark. In addition, spreading health education regarding topics such as handwashing,

common childhood diseases, or stress and anger management may decrease the likelihood of the

Noah’s Ark students coming to school stressed or sick. Sending home newsletters regarding

school topics and health promotion could be substituted for parent nights.

Implications for Community Health Nursing

This project with Noah’s Ark Christian Day School highlights the difficulties community

health nurses face in promoting positive change within an aggregate. At first, the nursing

students felt overwhelmed due to the inordinate number of problems they encountered. It was

difficult to find a single problem that, when corrected, would make a substantial impact on the

community and that could be addressed during the limited period available to the students. The

students chose to focus on education, hoping that this would provide a solution to a complex

problem and would provide the daycare with an enduring resource that they could apply to other

issues. However, the students found that focusing on a single objective did not resolve the

problem. Instead, it highlighted the additional issues that were involved, such as decrease in

staff morale and general lack of resources. Based on the experience with Noah’s Ark, it is clear


that community health nurses should use multimodal interventions in order to promote positive

outcomes.

Community health nurses must also balance the desires of their aggregate with their own

objectives, as these differing views may conflict. This conflict of interests was encountered by

the nursing students during the initial phase of the project at Noah’s Ark, and it impacted their

ability to implement the educational intervention. Although the initial assessment of the

aggregate indicated a need for improved hygiene, the director of Noah’s Ark was more

concerned with obtaining additional, tangible resources. As the students found out, these

resources were actually key to improving conditions at the facility. In retrospect, using this

request as guidance could have influenced the nursing students toward pursuing the interventions

proposed in the recommendations section of this paper. It is therefore important for community

health nurses to consider the underlying reasoning behind the requests of their aggregate and use

that information as they develop interventions.

Conclusion

In conclusion, the relationship that a community health nurse develops with the aggregate

should reflect their combined goals and strengths, enabling the community and the nurse to

tackle their complex problems together. Noah’s Ark provided the students with an opportunity

learn about forging this relationship, assessing a community group, and implementing

interventions with the goal of improving the health of this aggregate. They experienced the

complexity of the problems that community health nurses face first hand. This project gave the

nursing students of Old Dominion University a taste of what it means to be a community health

nurse and valuable experience that can be applied to their practice in any setting.


References

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Appendix

Teaching Plan

Teaching for each disease will be between 3-5 minutes.

This will allow time for questions at the end.

Also a tri-fold board will be present to show more picture of the diseases that show

physical signs that the teachers should know about.

Hand-outs of these outlines will be presented

Pre and Post test will be given to evaluate the effectiveness of teaching


Test 1. What is the best way to keep sickness from spreading?

a. shots which prevent children from getting sick

b. wash your hands

c. use gloves

d. stay away from sick children

2. What is another name for the norovirus?

a. sick children disease

b. stomach flu

c. pink eye

d. none of the above

3. What symptom differentiates strep throat and flu?

a. sore pain

b. fatigue

c. swollen tonsils with red spots on roof of mouth

d. vomiting

4. A child can get ringworm from:

a. touching a person with ringworm

b. using other people’s personal items

c. common areas like gym, shower stalls

d. contact with hair or dander of an infected animal

e. all of the above

5. RSV is a disease that affects the:

a. heart

b. skin

c. lungs

d. brain

6. When should a child be seen by doctor immediately in reference to the flu:

a. trouble breathing

b. headache

c. chills

d. runny nose

1. When should antibiotics be stopped:

________________________________________________________________________

________________________________________________________________________

__________________________________________________

2. What kind of cream should be used for ringworm: ______________________________

3. True or False RSV will die on a surface within in five minutes.

4. Influenza affects

the:_________________________________________________________________


Strep Throat (streptococcal pharyngitis)

Presenting Signs/Symptoms:

throat pain

trouble swallowing

red/swollen tonsils (may or may not have white patches/streaks of pus)

tiny red spots at the back roof of the mouth

fever, headache

swollen lymph nodes in neck

rash

stomachache

sometimes vomiting

fatigue

Should they go home? Is it

contagious?

If the child has symptoms

for more than 48 hours,

he/she should see a doctor.

If the child has a fever

he/she should be sent home

and referred to a doctor for

further testing.

Strep throat is highly

contagious. Strep can be

contagious before symptoms

show. Close monitoring of

other children is imperative.

When can they come back? (ex.

after fever has broken etc.)

A doctor should see the child if strep is suspected.

The child may return after 24 hours of antibiotics and the fever has subsided.

What to educate parents:

If the child has tested positive for strep it is important to encourage the parents to make

sure the child receives all of their antibiotics. Encouraging good coughing etiquette, good

hand hygiene, and making sure personal items are not shared are important.


Influenza (Flu)

An infection of the nose, throat and lungs caused by influenza viruses

Many different influenza viruses that are constantly changing

Children younger than 5 and especially children younger than 2 are at risk

Each year about 20,000 children younger than 5 years old are hospitalized from flu

complications, like pneumonia

How does it spread?

Spread by droplets, people with flu can spread it to others up to about 6 feet away.

Coughing

Sneezing

Talking


Usually comes on suddenly

Fever or feeling feverish/chills

Cough

Sore throat

Runny or stuffy nose

Muscle or body aches

Headaches

Fatigue (tiredness)

Some may have vomiting and diarrhea, though more common in children than adults

Should they go home? Is it contagious?

Yes

Able to infect other people beginning 1 day before symptoms develop

Adults can spread the virus up to 5 to 7 days after becoming sick

Children may pass the virus longer than 7 days

When they can come back?

24 hours after their fever is gone


Educate parent to seek medical care

Make sure the child gets plenty of rest and drinks enough fluids

If child is younger than 5 and has any health conditions (asthma etc.) they are at risk for

serious complications and a doctor should examine the child


Medical emergency

Take the child to the doctor right away if they experience:

o Fast breathing or trouble breathing

o Bluish or gray skin color

o Not drinking enough fluids

o Severe or persistent vomiting

o Not waking up or not interacting

o Being so irritable that the child does not want to be held

o Flu-like symptoms improve but then return with fever and worse cough

Has other conditions (like heart or lung disease diabetes, or asthma) and develops flu symptoms,

including a fever and/or cough


Norovirus

Norovirus is a very contagious virus that causes nausea, vomiting, and diarrhea in people, also

known as the “stomach flu”


Nausea, vomiting, diarrhea, stomach cramping, low-grade fever, chills, headache, muscle

aches and general feeling of tiredness


Child is contagious from time symptoms appear up to 3 days after feeling better

Child may return to daycare 48 hours after symptoms have stopped

What to educate parents?

WASH HANDS and provide child with plenty of fluids to prevent dehydration


Respiratory Syncytial Virus (RSV)

● Virus that causes respiratory infections

● Most commonly spread in childcare facilities

How does it spread?

● Coughing

● Sneezing

● Shaking hands

● Can stay on hard surfaces for hours


● First Symptoms 4-6 days after exposure:

○ Runny nose

○ Decreased Appetite

● Next signs/symptoms:

○ Coughing

○ Sneezing

○ Fever

● Late Sign:

○ Wheezing

○ Breathing difficulties and

inactivity seen in infants


● Yes

● Contagious for 3-8 days

● Can live on surfaces for many hours

When can they come back? (ex. after fever has broken etc.)

● Full recovery occurs in 1-2 weeks


● Educated parents to seek medical care

● Encourage to bleach surfaces that the child has come in contact with

● Wash hands frequently

● Avoid sharing cups, eating utensils, etc.


Ringworm

Ringworm is an infection of the skin, hair, or nails caused by a fungus

It gets its name from its appearance on the skin, because the rash is often ring-shaped.

Not actually caused by a worm

How is it spread?

Touching a person who has ringworm.

Using items such as clothes, towels, or hairbrushes that were used by someone with a

ringworm infection.

Coming into contact with the hair or dander of an infected animal.

Using common areas like gyms, shower stalls, and floors if used by someone with

ringworm.


scaly, crusted rash that may appear as round, red patches on the skin

patches of hair loss or scaling on the scalp

Itching

Blister-like lesions.


Yes, the child should go home since ringworm is highly

contagious

When can they come back?

24-48 hours after treatment starts


Notify the child’s parent(s) if ringworm is suspected. If known, ask if child is being

treated.

Make sure that areas with ringworm are covered by clothing or a gauze dressing. The

child’s

Personal items should not be shared with any others, and bedding should be washed with

hot water and soap to kill the fungus.

Anti-fungal cream or ointment should help get rid of the ringworm patches.


Old Dominion University Honor Code

“I pledge to support the Honor System of Old Dominion University. I will refrain from

any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as

a member of the academic community, it is my responsibility to turn in all suspected violators of

the Honor Code. I will report to a hearing if summoned.”

Health Planning Project II: Noah s Ark Rebecca Cominoli ... · Health Planning Project II: Noah’s Ark Noah’s Ark Christian Day School is located in Mason Memorial Church and provides

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