NOVEMBER 200 I , VOL 74, NO 5 Schrecengost

Do Humorous Preoperative Teaching Strategies Work?

A growing body of research points to the ther- apeutic value of humor. Some believe that humor establishes a warm atmosphere, relieves stress, and enhances the learning process.’ Humorous teaching strategies facil-

itate open, flexible communication and allow patients to ask questions they otherwise may not ask and hear instructions they otherwise may not hear.Z Although Vera Robinson, FW, EdD, a pioneer in the field of humor and nursing, first encouraged the use of humor in the health care setting,’ humorist Norman Cousins popularized it as a therapeutic Using humor in health care is as ancient as healing itself, but during the past 20 years, its use has been rediscovered.’

Humor can help establish the nurse-patient rela- tionship or the teacher-learner relationship. “Breaking the ice” in preoperative teaching can help nurses gain patients’ attention, decrease their anxiety, and increase their knowledge retention: Humor has

A B S T R A C T

been shown to facilitate and enhance the learning process,7 and cartoons have been used to illustrate ideas, behaviors, or attitudes.’ Humor should not replace other teaching methods, but it can strengthen illustrations and principles conveyed to patients dur- ing preoperative tea~hing.~

Preoperative teaching prepares patients for preop- erative and postoperative expectations and aims to limit potential postoperative complications.’” Literature shows that preoperative teaching should focus on immediate learning needs, and long-term issues should be taught and reinforced during discharge instruction.” A common preoperative teaching strategy is for nurses to provide patients with written material and reinforce that material with oral instruction. Limited research has been conducted on the relationship between the use of humor as a teaching strategy and the assessment of knowledge after preoperative teaching. This study par- tially replicates a previous study conducted to deter-

mine whether the use of humor in preoperative instruction affects patients’ recall of this instruction.”

Incorporating humor into preoperative teaching may improve patients‘ ability to recall pertinent instruction. This article describes a study in which an experimental, two-group, pretest/posttest design was used to determine whether there was a significant difference in the amount of knowledge patients recalled after receiving a teaching booklet either with (ie, experimental) or without (ie, control) humor. The sample included 50 patients undergoing open-heart surgery. Results indicate that there was no significant difference (iz1.48 = .07, P > .05) between the groups in the amount of knowledge gained related to postoperative pulmonary exercises. Both groups, however, had a statistically significant increase in the amount of knowledge gained from pretest to posttest (6.48 = 39.16, P < .05). Before humorous teaching strategies can be recommended for use in pre- operative teaching, further research about the relationship between preoperative instruction, humor, and knowledge retention is neces- sary. AORN J 74 (Nov 2001) 683-689.

PROBLEM STATEMENT With the demands of man-

aged care and early patient dis- charge, nurses need more effective preoperative teaching methods. Nurses have limited time to instruct patients regarding postop- erative pulmonary exercise behav- iors. They must evaluate their role in the delivery of nursing services to ensure that care is provided in a safe, professional, and cost-effec- tive manner. According to one researcher, incorporating humor in preoperative teaching material

A N N S C H R E C E N G O S T , A R N P

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NOVEMBER 200 1, VOL 74, NO 5 Schrecengost 9

may increase patients’ knowledge gain.” Further research on the effects of incorporating humor in pre- operative teaching is needed.

SnJ~puRpOsE The purpose of this study was to determine the

efficacy of humor in preoperative teaching about postoperative pulmonary exercise routines on knowl- edge retention in patients undergoing open-heart sur- gery. The following research question guided this study: Is more knowledge retained in the experimen- tal group receiving humorous preoperative instruc- tion compared to the control group receiving routine teaching without humor?

vcoII\TuRERMLw One researcher found that there was no significant

difference in the preoperative anxiety of patients who received either humorous distraction, musical distrac- tion, or no intervention (F2. I 2 = 1.48 P = -267)’‘ The results, however, indicate that patients in the humor group reported the lowest level of anxiety, and patients in the control group reported the highest level.Is This researcher later examined a larger sample to study the same relationship between humor and preoperative anxiety.I6 Results again suggest that there was no sig- nificant difference in anxiety scores between groups.”

Another group of researchers evaluated the effect of cartoons on patient comprehension of and compliance with wound care instructions provided in the emergency room.’s In a prospective, randomized study, 234 patients who presented to the emergency room with simple lacerations were given discharge instructions that either did (ie, experimental group) or did not (ie, control group) contain cartoons. Results of the study show that patients in the experimental group were more likely to have read discharge instructions, more likely to answer all of the wound care questions correctly, and more compliant with daily wound care. According to this study, cartoon illustrations are an effective teaching strategy and may improve patient compliance with emergency room discharge instructions.”

One researcher conducted a study to determine whether the use of humorous preoperative teaching techniques affects patients’ recall of instruction regarding postoperative exercise routines.” Results indicate that patients in the nonhumor group (ie, control) performed better on the pretest compared to patients in the humor group (ie, experimental); how- ever, patients in the humor group performed better on the posttest. No significant statistical difference was noted between patients in the groups on knowl- edge of postoperative exercises ( t = -1.02, df = 22, P > .05).2’ Another researcher conducted a partial

replication of this study.’* Results indicate that patients in the treatment group did better than patients in the control group on the pretest and the posttest; however, the results were not statistically significant ( t = .73, P > .05).23

M- The setting for this study was a 297-bed federal

teaching facility located in west-central Florida. On average, the facility performs 222 open-heart surger- ies per year. The pretest, posttest, and treatment phas- es of the research study took place in patients’ hospi- tal rooms.

The target population included all patients under- going nonemergent coronary artery bypass graft (CABG) or valve surgery. In a nonprobability con- venience sample, 50 patients scheduled for open-heart surgery who were older than 21 years of age were assigned randomly, by coin toss, to one of two groups. Inclusion criteria for the study were that the patient

was undergoing a nonemergent CABG or valve procedure; was admitted the day before the procedure; was alert and oriented to time, place, and people; was able to speak, write, and read English; was willing to participate; and had not undergone any other major abdominal, lung, or heart procedure during the past six months.

Instrumentation. The Postoperative Exercise Routine-Knowledge Test (PER-KT) was used as the pretest and posttest, and the researcher who devel- oped this tool granted permission for its use in this study.24 The PER-KT is a nine-item true-false test designed to measure patients’ knowledge of three postoperative pulmonary exercisesdeep breath- indcoughing, turning in bed, and early ambu la t i~n .~~ The pretest and posttest contain the same items, but items are presented in reverse order on the posttest. A panel of perioperative experts evaluated content validity of the test, but a result was not reported by the researcher. The instrument never was tested for reliability. Knowledge retention was scored by the number of questions answered correctly on the PER-KT, with the highest score being nine.

Znterventioa A researcher-developed teaching booklet, written at a fifth- to sixth-grade reading level, was used to instruct patients about the three postoperative pulmonary exercises tested in the PER- KT. The booklet given to patients in the experimen- tal group differed from the control group’s booklet only in that it included three cartoons, one represent- ing each of the three postoperative exercises. The car- toons were developed by a professional graphic artist and were used by a previous researcher who granted

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NOVEMBER 2001, VOL 74, NO 5 Schrecengosr

METHOD NOTE

slotlstlcal Lknltatiorrsdchange creores The pretesffpastkst (is, belore/afler) research design is experimenfol and a -1 inelhod used to test muse- effect relationship^.^ In this study, a pmtast/pcdlesf design was used to detwninewhetherlhere had been a change in the amount of kwwkdge obaut posroperatve pulmonary exercise routines 0s a mil of using humor- ouspreoperativeinstructiocl.WIhemscoreofa research portlcipant was h@mr than the pceDest w e , #e researcher concluded that learning had resulted. A change w e (ie, dllbmce score, gain m) is the posttest score minus tne prelest scare.? in this study, the researchersoughttodslerminewhetherlhechonge SCOIB or patients M O had recehred humorous preoper- ativeteachingwere largerthan thosedpatfentswho had received preopemthre mng wnhoul hum.

Pretest and posttest scores also may have miling effects or floor effects that determine Ihe m a x i m amount of change that is possible. If the pretest scores of patrents are high, there is lmle room for change resulting from the expenmental Ireatment, thus the change SaxeS may

be small.' In this study, 40% of pohents obtained a scored 7 01 higher out of 9 items on the pretest, and only 26% Or panents hod a gain score of3 or more points. These factors may account for the lack of signifl- cant difference bdwm the groups in lhe amount of knowledge gained.

Perhups the most significant problem with this Iype of study design is the use of the same instrument as botn a pretest and posltestmeoswe. In this study, the order of items w(1s revawl on lhe posltest; however, wilh only 9 items and a shad time penod beiween pmbst and posttat, there is a tendency for participants to remember the tlems and ScMe betterthe second time based on this knowledge. This phmmfmn is known 0s subject sensmzation. Addiiionalty, if a group of indi-

vidual SCMBS tend to come closer to the meon score for the group. This is a unh/srsal stdistical phenomenon called regression toward the mean! Any changes in an individual’s scorn may be due to thew phenomena and not to the intetvention, which, in Ihis case, was the inclusion of humor in teachtng booklets.

VldWlS takes the Sam test mOre !lWfI OMX, their lndl-

nut@ Lorsen, RN, MN. is a dxtorrrl student, h q u a n e Universi& School of Nursing. Pithburgh.

Kotirlepn K Caberson, RN, PhD, is a profaso,: hquesne Universiq School of Nursing, PitBburgh.

NOTES 1. D F Poli, B P Hungier, Nurs’w l&wtnch: principles and MVwds, sixlh ed (philadelphla: J B Uppincott.

1989) 180- 181; G L&ondo-Woad, J Wmr, Num’q Rtwarch: Mwd9, Cri&vl AcyKalwl, and UYilizatkm, fourth ed(StLouls: Masby, 1998) 174161.

2, C FWaltz, OsMddand, E R Len& h&wm?nmt/n Nusing Rmknch, seconded (Philadelphia: F A Davis Ca, 1991) 103-104; D F Wit, eota Analysis and SAMks RK Nursing /&?semh (Stamford, Conn: &&#on & Lange, 1996) 317.

3. Waltz, ShWaM, Lea?., -in Nusing RismM, second ed,104. 4. Polit, ~ A n d p ~ / ~ o n d ~ k x l v l K s i n g ~ f C h , 317. 5. P A Dempsey, A D Dempse~, Ww Nt@w m: procesS. ml CAnd lHi//Mh, Mh ed

(Baltimor~: J B Lippincott, 2000) 155.

permission to use them in this study.’6 Approvals. The investigator obtained approval

to conduct the study from the following authorities at the study institution:

the privacy officer, the research and development committee, the chief of surgery, the chief of nursing, and

the chief of pulmonary medicine. The institutional review board of the University of South Florida, Tampa, also granted permission.

Research design. The researcher used an exper- imental, two-group, pretest/posttest research design to determine whether there was a significant differ- ence in the amount of knowledge recalled after patients received a teaching booklet either with (ie,

685 AORN JOURNAL

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experimental) or without (ie, control) humor. From April to August 1999, the researcher contacted the unit charge nurse to identify potential study subjects. After the purpose of the study was explained briefly to subjects, informed consent was obtained. In an interview, the researcher completed the demographic data form, which included the date of intervention, surgical procedure, place of intervention, and patients' age, gender, and level of formal education. Table 1 illustrates the data collection procedure.

RESULTS During the five-month study, 55 patients were

approached. Five patients refused to participate due to lack of interest (n = 2), anxiety (n = 2), and a negative past experience with participating in a research study (n = 1). Complete data were obtained for 50 patients- 27 were randomized to the experimental group, and 23 were randomized to the control group. One patient included in the study decided not to undergo surgery on the morning of the scheduled procedure.

Sample. The 50 study subjects were males between the ages of 44 and 80 with a mean (M) age of 61.1 (standard deviation [SD] = 9.4). The mean age of patients in the experimental group (M = 62.6,

Table 1 DATA COLLECTION PROCEDURE

Researcher briefly explains the purpose of the study

Patient reads and signs consent form

f 5minutes

10 minutes ~ Randomized to

\ Control group Experimental group (ie, no humor) (ie, humor)

Pretest Postoperative Exercise Routine-Knowledge Test (PER-KT) administered

Patient reads teaching booklet either with or without humor

'c lhour

Posttest PER-KT administered

Questions are answered

\ / 5minutes

f lominutes

lominutes

SD = 9.7) was slightly higher than that of patients in the control group (M = 59.4, SD = 8.9). There was no significant difference between groups in the type of surgical procedure undergone. Patients in both groups had similar education levels, with most sub- jects having at least a high school education. The place of intervention also was recorded because of the possibility that subjects who were in the intensive care unit before surgery may have experienced a greater level of anxiety, which possibly affected the knowledge scores. Most subjects were on the med- ical-surgical floor preoperatively (Table 2).

PER-KT analysis. There was a knowledge gain for patients in both groups as a result of structured preoperative education. On the pretest, 40% of patients scored seven or higher out of nine items as compared to 76% of patients on the posttest. Pretest scores ranged from two to nine, with only one subject in the experimental group getting all nine correct. Posttest scores ranged from four to nine, with 30% of patients getting all nine items correct. Twenty-six percent of the sample experienced a gain of three or more points from pretest to posttest.

Research question. A two-way analysis of vari- ance (ANOVA) test showed that there was no statis- tically significant difference between groups in the amount of knowledge gained ( F 1 , 4 8 = .07, P > .05). There also was no statistically significant difference between groups fkorn pretest to posttest (F,, 48 = 1.37, P > .05), although the results presented in the pre- dicted direction. Patients in both groups showed a statistically significant improvement from pretest to posttest (F1.a = 39.16, P < .05) as shown by the mar- ginal means of 5.860 on the pretest and 7.380 on the posttest (Tables 3 and 4).

MscussH)N Patients in both groups showed a significant

increase in knowledge after preoperative teaching. Although the amount of change did not differ signifi- cantly between the groups, it was in the predicted direction. Patients in the experimental group improved their score by 1.778 points, and patients in the control group improved their score by 1.217 points. The lack of statistical significance may be due to insufficient reliability or power.z7 The PER-KT has low reliability on both the pretest (Cronbach a = .58) and on the posttest (Cronbach a = S2). Inter-item correlations show that the mean on the pretest was 0.14 and on the posttest was 0.12. There also is a known inherent sta- tistical weakness in comparing gain scores.

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In the ANOVA, the test of interaction had an esti- mated power of 0.209. The size of this interaction was quite small (eta2 = .028). To achieve a power of 0.80 to detect this small effect, one would need a sample size of 4,362 subjects per group or a total of 8,724 subjects. This requirement obviously is beyond the scope of this study.

Compared to previous studies? this study did improve on certain methodological procedures, including increasing the sample size to 50, compiling a more homogeneous sample of patients undergoing the same type of surgical procedure, and limiting the sample to exclude patients who had undergone major surgery during the past six months because they may have had recent experience with pulmonary exercises. Results from a previous study are similar to the results of this study?’ They show that patients in the con- trol group did better on the pretest than patients in the treatment group, but patients in the treatment group performed better on the posttest than patients in the control group. The gain knowledge scores, however, were not significantly different ( t = -1.02, df= 22, P > .05). In yet another study, patients in the treatment group did better on the pretest and posttest than did patients in the control group, but the difference between groups was not statistically significant (t = 0.73, P > .05).30

Different methodologies were used to collect data in all three studies. One researcher administered the posttest to sub- jects immediately after they read the teaching booklet.?’ Another researcher administered the posttest 30 minutes after subjects read the booklet,32 and the researcher in this study adminis- tered the posttest one hour after subjects read the booklet. All researchers used different teach- ing booklets. This researcher used the same cartoons as a previous researcher.” The third researcher used different cartoon^.^^ If this study were to be replicated, it is

Table 2

suggested that the same teaching booklet with the original cartoons be used and that the same data col- lection procedures be followed.

Although there was no significant difference in knowledge gain between groups regardless of whether patients received humorous teaching, no conclusive evidence was found not to use humor as a teaching strategy. Humor may not have been respon- sible for patients’ knowledge gain, but something helped them learn about pulmonary exercises. It is possible that the additional structured preoperative teaching helped. It also is possible that patients viewed learning about postoperative pulmonary exer- cises as a short-term way to hasten recovery after sur- gery. This may have enhanced patients’ ability to

DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE

Variable Control Experimental Total Percentage

Gender n = 23 n = 27 50 Male 23 27 50 100 Female 0 0 0 0

Planned procedure Coronary artery bypass graft (CABG) 17 RedoCABG 2 CABGand aortic valve 2 CABGand mitral valve 1 Aortic valve 1

Level of education Less than

High school high school 6

diploma 10 Some college 3 College degree 3 Master’s degree 0

master’s degree 1 Greater than

Place of intervention Medical-surgical floor 19 Intensive care unit 4

19 5

3

0 0

5

10 6 5 1

0

36 7

72 14

5 10

2 2

1 1

2 0 9 8 1

1

23

4

42

a

22

40 18 16 2

2

84

16

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Table 3 MEANS AND STANDARD DEVIATIONS FOR POSTOPERATIVE EXERCISE ROUTINE-KNOWLEDGE TEST SCORES

Pretest mean Posttest mean Collapsed (standard (standard overtime

Group n deviation) deviation) mean

Control 23 5.957 (1.846) 7.174 (1.403) 6.566 Experimental 27 5.778 (1.649) 7.556 (1.396) 6.667 Total 50 5.860 (1.726) 7.380 (1.398) 6.620

The highest score is 9.

Table 4 ANALYSIS OF VARIANCE FOR POSTOPERATIVE EXERCISE ROUTINE-KNOWLEDGE TEST KNOWLEDGE GAIN

Source Sumof souares df Mean sauare f P

Group (1, 2) 0.26 1 0.26 0.07 >.05 Error term 176.30 48 3.57

Ime (prdpost) 55.71 1 55.71 39.17 <.05

Group x time 1.95 1 1.95

Error term 68.29 48 1.42

recall information. Regardless of the reason, patients in this study significantly improved their knowledge scores from pretest to posttest. Before humorous teaching strategies can be recommended for preoper- ative instruction, increased knowledge about the rela- tionship between preoperative teaching, humor, and knowledge retention is necessary.

RLCOMMENDAllONS If this study were to be repeated, several areas

could be improved. First, data collection might be conducted in multiple centers to increase the external validity of the findings. The small convenience sam- ple of only older adult men undergoing open-heart surgery prevents generalizability to other geographi- cal locations and surgical populations. It also is diffi- cult to generalize these results to women. Second, it is recommended that the sample size be increased significantly to increase power. Third, the instrument used in the study, which has very low reliability, must

be improved and revised. Sug- gestions for improvement consist of including more items on the test, using multiple-choice items, and rewording current items for clarity and relevance. Revising the PER-KT before replicating this study may improve the power of the statistical test, thereby reduc- ing the sample size required.

A fourth suggestion is to strengthen the intensity of the intervention to possibly produce a larger treatment effect. This could be accomplished by using different humorous teaching methods, such as comic films, teaching booklets with more cartoons, or humorous oral instruction (eg, being dressed like a clown). Finally, given that excessive anxiety interferes with learning, the life threatening nature of open-heart surgery may have

1’37 >‘05 undermined the effectiveness of humorous preoperative education; therefore, providing patient educa- tion the night before surgery when

anxiety is high may alter the results of the study. The use of humorous preadmission education also could be explored.

Due to the nonsignificant results of this study, it would be difficult to recommend humorous teaching strategies for use in nursing practice and education. Further research is needed to determine the value of humor as a nursing intervention. Although humor has not been empirically shown to improve patient out- comes, it should not be discounted as an effective adjunct to skillful nursing care. A

Ann Schrecengost, ARNR MSN, ACNR is a nurse prac- titioner in the gvnecology suygery program, James A. Haley Veterans Afsairs Hospital, Tampa, Fla.

The opinions or assertions contained in this article are the private views of the author and are not to be con- strued as oficial or as rejecting the views ofthe Department of Veterans Affairs.

NOTES

“Facilitate learning with humor,”

Journal of Nursing Education 27 (February 1988) 89-90.

peutic approach in oncology nurs- ing,” Cancer Nursing 12 (April 1989) 65-70.

1 . M J Watson, S Emerson, 2. J L Bellert, “Humor: A thera-

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3. V M Robinson, Humor and the Health Professions (Thorofare, NJ: C B Slack, 1977).

4. N Cousins, Anatomy of an Illness as Perceived by the Patient: Reflections on Healing and Regeneration (New York: W W Norton and Co, 1979).

ing intervention,” Cancer Nursing 16 (February 1993) 34-39.

6. E Glass, “Humor helps to ‘break the ice’ during patient educa- tion,” Oncology Nursing Forum 20 (July 1993) 965.

7. V Robinson, Humor and the Health Profession: The Therapeutic Use of Humor in Health Care, sec- ond ed (Thorofare, N J Slack, Inc, 1991)

8. L A White, D J Lewis, “Humor: A teaching strategy to pro- mote learning,” Journal of Nursing StafDevelopment 6 (MarchiApril

5. A H Hunt, “Humor as a nurs-

1990) 60-64. 9. J P Ruxton, “Humor interven-

tion deserves our attention,” Holistic Nursing Practice 2 (May 1988) 54- 62.

erative teaching: Effect on recall of postoperative exercise routines,” AORN Journal 52 (July 1990) 114- 120.

11. J M Steele, D Ruzicki, “An evaluation of the effectiveness of cardiac teaching during hospitaliza- tion,” Heart andLung 16 (May

10. J M Parfitt, “Humorous preop-

1987) 306-311. 12. Parfitt, “Humorous preopera-

tive teaching: Effect on recall of postoperative exercise routines,” 114-120.

1 3. Ibid. 14. K B Gaberson, “The effect of

humorous distraction on preoperative anxiety,” AORN Journal 54 (Dec- ember 1991) 1258-1264.

15. Ibid. 16. K B Gaberson, “The effect of

humorous and musical distraction on preoperative anxiety: AORN Journal 62 (November 1995) 784-791.

17. Ibid. 18. C Delp, J Jones, “Com-

municating information to patients: The use of cartoon illustrations to improve comprehension of instruc- tions,” Academic Emergency Medicine 3 (March 1996) 264-270.

19. Ibid. 20. Parfitt, “Humorous preopera-

tive teaching: Effect on recall of postoperative exercise routines,” 114-120.

2 1. Ibid. 22. C A Oberle, “The Effect of a

Humorous Preoperative Teaching Strategy on Knowledge of Postoperative Exercise Routines: A Partial Replication” (master’s thesis, University of Duquesne, Pittsburgh) 1995.

23. Ibid. 24. Parfitt, “Humorous preopera-

tive teaching: Effect on recall of postoperative exercise routines,” 114- 120.

25. Ibid. 26. Ibid.

27. M K Kachoyeanos, “The sig- nificance of power in research design (Part I),” MCN: The American Journal of Maternal Child Nursing 23 (MarcWApril 1998) 105.

28. Oberle, “The Effect of a Humorous Preoperative Teaching Strategy on Knowledge of Postoperative Exercise Routines: A Partial Replication”; Parfitt, “Humorous preoperative teaching: Effect on recall of postoperative exercise routines,” 114-120.

tive teaching: Effect on recall of postoperative exercise routines,”

30. Oberle, “The Effect of a Humorous Preoperative Teaching Strategy on Knowledge of Postoperative Exercise Routines: A Partial Replication.”

3 1. Parfitt, “Humorous preopera- tive teaching: Effect on recall of postoperative exercise routines,”

32. Oberle, “The Effect of a Humorous Preoperative Teaching Strategy on Knowledge of Postoperative Exercise Routines: A Partial Replication.”

33. Parftt, “Humorous preopera- tive teaching: Effect on recall of postoperative exercise routines,”

34. Oberle, “The Effect of a Humorous Preoperative Teaching Strategy on Knowledge of Postoperative Exercise Routines: A Partial Replication.”

29. Parftt, “Humorous preopera-

114-120.

114-120.

114-120.

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