A O R N J O U R N A L J U L Y 1990. VOL. 52, NO I

Humorous Preoperative Teaching EFFECT ON RECALL O F POSTOPERATIVE EXERCISE ROUTINES

Janice M. Parfitt, RN

reoperative instruction prepares a patient for preoperative and postoperative expec- P tations. Preoperatively, the patient is

prepared psychologically and physically for the scheduled procedure. One of the main purposes of preoperative instruction is to minimize postoperative complications that most often involve the respiratory, cardiovascular, or gastrointestinal systems.

Except for the addition of early ambulation after surgery, routine postoperative exercises have remained virtually unchanged since the “stir-up” regimen was first described in the 1940s.’ The stir-up technique consisted of helping a patient turn in bed while encouraging active movement of the arms and legs and emphatically insisting that the patient cough forcefully and breathe deeply to reinflate the lungs.

A common teaching strategy for providing preoperative instruction is to use printed materials,

which usually are supplemented by the nurse’s verbal explanations and demonstrations. There has not been much research on the effectiveness of printed materials for preoperative instruction. It is not known whether printed materials should be altered in some way to enhance the patient’s recall of instructions. One way of altering the printed materials might be to add a humorous teaching strategy.

Freud introduced the concept of humor to the psychological literature in the early 1900s. Freud believed that humor was “ . . . a means of obtaining pleasure in spite of the distressing effects that interfere with it.”* Freud’s influence on humor is seen in the social science and educational literature to this day. The appeal to health care professions is traced to Norman Cousins, who in 1976 related how laughter played a role in his recovery from a collagen disease.3

Since that time, the use of humor in health

clinical staff development coordinator, St Francis Medical Center, Pittsburgh. She earned her bachelor of science degree in nursing from Loma Linda (Calif) University and her master of science degree in nursing from the University of Pittsburgh.

The author acknowledges Kathleen B. Gaberson, RA? PhD, assistant professor, graduate program, School of Nursing, Duquesne University, Pitts- burgh, for her assistance in preparing this manuscript. She also acknowledges Mary Frances Borgman, RN, E D , Peggv Cato, and Rani Harrkon.

Janice M. Parjitt, RN, MSN was a nursing education specialist, Mercy Hospital of Pittsburgh, when this article was written. She current@ is OR

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Table 1 Postoperative Exercise Routine - Knowledge Test

Directions: Please mark each statement either true or false.

1.

2.

3.

4.

5.

6.

7.

8.

9.

Walking should be started when you feel ready to do so. True False

Frequent turning helps to stimulate blood circulation. True False

Deep breathing expands the lungs after surgery. True False

Early walking after surgery can cause injury. True False

Coughing should be done gently to avoid pain. True False

Turning in bed should be done only when you feel like it. True False

Early walking helps improve the blood circulation. True False

Frequent turning helps maintain skin in good condition. True False

Coughing and deep breathing help prevent pneumonia. True False

care with students, patients, and coworkers has been documented in literature.4 Humor has been proposed as both a teaching and learning strategy in the health care professions, but little research has been done to investigate its effectiveness.

Before humorous teaching strategies can be recommended for preoperative teaching, an increased understanding of the relationship between preoperative teaching, humor, and the recall of learning is necessary. This study investigated the effect of humor as a teaching strategy on preoperative patients’ recall of information about postoperative exercise routines.

Study Purpose

he purpose of this study was to determine if there was a difference in the recall of T postoperative exercise routines in patients

who received humorous preoperative teaching compared with patients who received preoperative teaching that was not humorous. This study did

not test patients for learning retention or application of postoperative exercise routines. Because this was an initial study, only the recall of written information was examined. Therefore, no attempt was made to evaluate subjects’ abilities to demonstrate the actual postoperative exercise routines.

The research question of this study was, “Does the use of a humorous preoperative teaching technique affect the recall of instructions about postoperative exercise routines ?.,

Methodology

he researcher submitted a proposal for the study to the Psychosocial Institutional T Review Board of the University of

Pittsburgh and obtained approval before initiating the study. Permission to conduct the study also was obtained from the nursing administrator of the hospital where the research was conducted.

An experimental two-group pretest/posttest

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AORN J O U R N A L JULY 1990, VOL. 52, NO I

Figs 1-3 @ Larry J. Fink, Palmyra, Penn, 1988. Reprinted with permhion

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JULY 1990, VOL. 52, NO 1 AORN JOURNAL

I . , 1 1 i

five five five researcher 1 minutes 1 consent read I I pretest I administered - explained study and signed - -

minutes administered answered - read booklet I

Fig 4. Time sequence of the study.

research design was used to determine if there was a difference in knowledge recall between patients who received humorous preoperative teaching and those who received preoperative teaching that was not humorous. The humorous teaching technique was the independent variable that was controlled in this study. Subjects were randomly assigned to treatment (humorous) or control (not humorous) groups.

The sample comprised 24 subjects under the care of any one of four surgeons who gave permission for their patients to be asked to participate in this research study. The subjects were scheduled for general surgery during August, September, or October 1988, and admitted to the hospital at least the day before their surgery. They were adults between the ages of 21 and 76 who could read, write, and speak English. The sample was one of convenience and nonprobability, with the first 18 subjects randomly assigned to either the control or treatment group by lottery. The last six subjects were assigned to the treatment group to ensure equal group size.

The setting for this research study was a 320- bed community hospital located near a large Northeastern city. The pretest, posttest, and treatment phases of the research took place in the subjects’ hospital rooms. The researcher performed all teaching on a one-to-one basis. Subjects were unaware that there were actually two methods of instruction until after the study.

The researcher developed an instrument called the Postoperative Exercise Routine-Knowledge Test (PER-KT) (Table 1). The test consists of nine true or false statements that measure the level of

knowledge about three postoperative exercise routines: coughing and deep breathing, turning, and ambulating. A panel of perioperative experts established content validity. The panel included two operating room supervisors and four surgeons. Panel members said that the items represented expected behaviors and that the three exercise routines were balanced because there were three items from each. They also agreed on the correct answers.

A professional graphic artist was employed to develop cartoons for the treatment group preoperative instruction booklet. The researcher provided the artist with ideas and guidelines to create the humorous teaching intervention. The cartoons were to be patient related, to use very few words, and to be overtly funny. There were a total of three cartoons, one for each of the postoperative exercise routine concepts (Figs 1 - 3). In a pilot test of the materials, six patients’ reactions were assessed to determine the construct validity of the cartoons. One cartoon was revised based on negative reaction to it.

Because most third-party payment systems limit the time allowed for hospitalization, the day of admission often is the day of or the day before surgery. This study only included patients who were admitted the day before their scheduled surgery. On the day of admission, the researcher contacted the unit charge nurse to prevent patients from receiving any preoperative teaching before they had the opportunity to participate in the study. That same day, the researcher met with potential participants, and in most cases, preoperative teaching had not been initiated.

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Sex Female Male

Age 20-29 30-39 40-49 50-59 60-69 70-79

Table 2 Characteristics of the Sample (n =24)

Group Control Treatment

Surgery Liver biopsy Bowel resection Hickman catheter insertion Cholecystectom y Herniorrhaph y Hysterectomy Mastectomy Splenectom y

8 5 4 7

2 2 0 0 0 1 2 I 7 6 1 2

The researcher briefly explained the purpose of the study. The researcher took measures to ensure that participants’ rights were protected and that their responses remained anonymous. Both the control and treatment groups were pretested with the nine-item PER-KT. Then, each patient was given a preoperative instruction booklet. The treatment group booklet differed from the control group booklet in that it included three cartoons that reinforced the routine postoperative exercises. A posttest form of PER-KT was given to both groups immediately after they read the preoper- ative instruction booklets. Figure 4 illustrates the time sequence.

Results

articipant characteristics and type of surgery revealed that the control and treatment P groups were equivalent (Table 2). Although

the control group had more female than male subjects, and male subjects predominated in the treatment group, this was not believed to be a significant difference.

An examination of pretest and posttest scores revealed that the control group performed better on the pretest than the treatment group did. On the posttest, however, the treatment group performed better than the control group (Table 3). The treatment group gained more knowledge than the control group. The posttest indicated no significant difference between the resulting knowledge of postoperative exercise routines ( I = -1.02, df = 22, p > 0.05).

Dkcussion

he results of the study indicate that the treatment group found the posttest easier T than the control group did. Humor may

JULY 1990, VOL. 52. NO I AORN JOURNAL

Table 3 Knowledge Gain Scores

for Control and Treatment Groups

Pretest Posttest Gain

Group Number Mean Standard Mean Standard Mean t deviation deviation

Control 12 6.33 1.23 7.17 0.84 0.84

Treatment 12 6.08 1.38 7.33 1.07 1.25 -1.02

have helped participants in the treatment group recall the information more easily, although this difference was not statistically significant.5 Other factors may have been responsible for the improved recall.

Despite the lack of statistical significance, the test score data analysis demonstrated some interesting findings. Both groups got more than half of the items correct on the posttest, and none of the subjects scored lower on the posttest than on the pretest.

It is possible that the lack of significant difference in knowledge gain was attributable in part to the simplicity of the test. Another possible explanation might be that the test may not have been sensitive enough to measure real differences in recall of postoperative exercise routines. Although the preoperative instructions used in this study were common, the experimental design attempted to control staff reinforcement and find a technique that was more effective. Before humorous teaching strategies can be recommended for preoperative teaching, increased understanding of the relation- ship among preoperative teaching, humor, and the recall of learning is necessary.

Limitations

here were several limitations to this research study. The manner in which T insurance payments have affected surgical

admissions and preoperative teaching by a variety of health care personnel were two uncontrollable

variables. The small convenience sample prevents generalization to the population. Because this was a pilot study, the instrument had not been tested for reliability. Bias might have been an added variable, although multiple teaching styles were controlled by the researcher who was the only instructor. Also, it was not determined whether the participants had previous experience with postoperative exercises. All of these limiting factors should be addressed when this study is replicated.

Conclusion

he use of humor as a teaching strategy and the assessment of knowledge gain after T preoperative teaching need further

research. Subsequent studies could investigate the retention of knowledge regarding postoperative exercises by evaluating the subject’s return demonstration. 0

Notes 1. R D Dripps, R M Waters, “Nursing care of surgical

patients: I . The ‘Stir-Up’,” American Journal of Nursing 41 (May 1941) 530-534.

2. S Freud, Jokes and Their Relafion to the Unconscious, trans J Strachey (New York City: Norton, 1960) 228.

3. N Cousins “Anatomy of an illness (as perceived by the patient),” The New England Journal of Medicine 295 (Dec 23, 1976) 1458-1463.

4. N W Moses, M M Friedman, “Using humor in evaluating student performance,” Journal of Nursing Educafion 25 (October 1986) 328-333; E Rosenheim, G Golan, “Patients’ reactions to humorous interventions

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in psychotherapy,” American Journal of Psychotherapy 40 (January 1986) 110-124; D B Leiber, “Laughter and humor in critical care,” Dimensions ofCritica1 Care Nursing 5 (May/June 1986) 162-170.

5. Ibid.

Suggested reading Christopherson, B Pfeiffer, C. “Varying the timing of

information to alter preoperative anxiety and postoperative recovery in cardiac surgery patients.’’ Heart and Lung 9 (September/October 1980) 854- 861.

Fox, V. “Patient teaching: Understanding the needs of the adult learner.” AORN Journal44 (August 1986)

Healy, K M. “Does preoperative instruction make a difference?” American Journal of Nursing 68 (January 1968) 62-67.

Lindeman, C A. “Nursing intervention with the presurgical patient: Effectiveness and efficiency of group and individual preoperative teaching-Phase two.” Nursing Research 21 (May/June 1972) 196- 209.

Lindeman, C A; Van Aernam, B. “Nursing intervention

234-242.

with the presurgical patient: The effects of structured and unstructured preoperative teaching.” Nursing Research 20 (July/August 1971) 319-332.

Marshall, J; Penckofer, S; Llewellyn, J. “Structured postoperative teaching and knowledge and com- pliance of patients who had coronary artery bypass surgery.” Heart and Lung 15 (January 1986) 76- 82.

McMorris, R F, et al. “Effects of incorporating humor in test items.” Journal of Educational Measurement 22 (Summer 1985) 147-155.

Roy, Sister C. Introduction to Nursing: An Adaptation Model Englewood Cliffs, NJ: Prentice-Hall, Inc, 1976.

Smith, R E, et al. “Humor, anxiety, and task performance.” Journal of Personaliry and Social

Townsend, M A R, et al. “Student perceptions of verbal and cartoon humor in the test situation.’’ Educational Research Quarterly 7 (Winter 1983) 17-23.

Wright, J E. “Using cognitive channels in patient education.” Dimensions of Critical Care Nursing 4 (September/October 1985) 308-3 13.

PSyChOlO~ 19 (August 1971) 243-246.

Psychological Test Helps Predict Recoveries To determine the success in treating workers with low back pain, orthopedic surgeons in Dallas developed a simple psychological test that pre- dicts which workers will recover and return to work, according to a Feb 10, 1990, press release from the Academy of Orthopaedic Surgeons.

The test measures stress, personality, and psy- chosocial factors that occurred around the time of the injury. Respondents were questioned about their educational level, personal and family situa- tions, jobs, and basic background data.

The questions were divided into three psycho- social categories: (1) a family and social index, (2) a psychosocial index on preinjury job factors, and (3) a psychosocial index on coping skills, financial difficulties, job-related questions, and questions assessing stability.

The test is used in conjunction with a physical examination and several diagnostic imaging tests (eg, computed tomography scans, myelograms, magnetic resonance imaging scans, electromyo- grams).

Six months later, the patient’s work status was assessed. Responses to the psychosocial indexes of the patients who returned to work were compared with those who did not. Patients who returned to work usually had a high school education, smoked less than 25 cigarettes a day, were single or living only with their spouse, and had not relocated their residence unless for a better job.

Patients who did not return to work reported their work physically hard, had worked at the job less than 26 weeks, and had problems coping with the injury emotionally or financially.

The 20-question survey was given to 143 workers’ compensation patients who underwent initial evaluations between October 1987 and March 1988. The physicians reported that the index correctly classified more than 85% of the patient who did not return to work.

The physicians developed the test at the Southwest Sports and Spine Center and Humana Advanced Surgical Institutes, both in Dallas.

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