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In presenting this professional paper in partial fulfillment of 
the requirements for an advanced degree at Montana State University, I 
agree that the Library shall make it freely available for inspection. 
I further agree that permission for extensive copying of this thesis for 
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without my written permission. 
Signature DcAyujV tfota- Un<Pe^crn> 
Date 4^.3 /9 7/  
Pages 138 - 165 inclusive 
NURSE’S GUIDE FOR USING THE MOTION PICTURE 
"YOU AFTER SURGERY: IMPORTANT ACTIVITIES" 
Copyright 
© Dolores A. Burger 1971 
A STUDY OF THE DEVELOPMENT AND USE OF A MOTION PICTURE 
WHILE TEACHING PREOPERATIVE PATIENTS ABOUT 
THEIR POSTOPERATIVE ACTIVITIES 
by 
DOLORES LOLA ANDERSON BURGER 
A professional paper submitted to the Graduate Faculty 
in partial fulfillment of the requirements for the degree 
of 
MASTER OF NURSING 
Approved: 
Head, Major Department 
( J — (r' ^ 
Chairmai^ Examining Committee 
Graduate l3ean 
MONTANA STATE UNIVERSITY 
Bozeman, Montana 
December, 1971 
Ill 
ACKNOWLEDGEMENTS 
To Miss Virginia Felton, Mrs. Elizabeth Diegel, Mrs. Barbara 
Hauf, and Dr. G. Hossack, I wish to express my sincere appreciation for 
the assistance they gave me as chairman and members of my graduate 
committee. 
It is impossible to adequately express my appreciation for 
the assistance given me by various other persons. Among these are 
Mr. Lee DeNike, on faculty in College of Education at Montana State 
University, Dr. Douglas Nixon of Eastern Montana College, and Mrs. L. 
Jourdonais, a graduate student, without whose help the preparation of 
the motion picture would not have been possible. 
The nursing service administration, nursing staff, and members 
of many other departments at Billings Deaconess Hospital, as well as 
surgeons practicing in Billings, all provided very essential help dur¬ 
ing the clinical part of this study for which I am grateful. 
Other members of the faculty of Montana State University, my 
husband, and friends have all contributed immeasurable help and 
encouragement Without which this study would never have been completed. 
TABLE OF CONTENTS 
Page 
VITA .     . ii 
ACKNOWLEDGEMENTS   iii 
LIST OF TABLES    . vii 
LIST OF FIGURES   .    x 
ABSTRACT   xi 
Chapter 
I. INTRODUCTION  ....... 1 
The Problems  7 
The Purposes  .........  8 
Assumptions   . .    . 9 
Hypotheses . .   9 
Limitations  10 
Methodology  .......... 12 
Definition of Terms  13 
Overview of the Remainder of This Study ...... 18 
II. REVIEW OF LITERATURE . . .   20 
Patients* Feelings, Concerns, and Nurse Behaviors . 20 
Preoperative Teaching Research Studies  27 
Motion Pictures: Learning and Retention  32 
Literature Concerning Stir-up  38 
V 
Chapter Page 
III. METHODOLOGY  .............. 54 
Introduction    54 
Development of Content for Film and Guide  57 
Planning and Production of Film   . 58 
Study Population   62 
Experimental Preoperative Patient-Teaching Outline 73 
Data Collection Tool  85 
Collection of Data . . . .   88 
Remainder of the Study  91 
IV. DATA AND ANALYSIS   92 
Introduction . . .    92 
Time Involved During Experimental Teaching .... 94 
Patients' Performance of Activities 
Postoperatively  99 
Patients' Postoperative Physiologic Status .... Ill 
Comments from Patients, Surgeons, and 
Nursing Staff     • 122 
V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS  128 
Summary      . 128 
Conclusions .      . . . 132 
Recommendations . . •  135 
vi 
Page 
APPENDICES 137 
A. Nurse’s Guide for Using the Motion Picture 
"You After Surgery: Important Activities" ....... 138 
B. List of Basic Equipment Needed for Super- 
8mm Film Production and Projection with 
Cost Estimates  166 
C. Data Collection Tool   168 
D. General Information of Patients in the 
Study Population . . .  169 
E. Surgical Intervention and Some Treatment 
Factors of Patients in the Study Population  173 
F. Distributions of Time with Patients During the 
Experimental Preoperative Teaching and Some 
Related Factors  ..... 178 
LITERATURE CITED  180 
LITERATURE CONSULTED 188 
LIST OF TABLES 
Table Page 
1. Frequency Distributions of Some Characteristics of 
Patients in the Study Population  66 
2. Frequency Distributions for Some Physical Factors 
Which Might- Affect Performance of Activities By 
Patients in the Study Population . . .     67 
3. Frequency Distribution of Control and Experimental 
Patients in Categories Based on Surgical Entry Site 
and/or Type of Surgical Procedure  69 
4. Type of Anesthetic Received and Duration of 
Anesthesia in the Operating Room  70 
5. Frequency Distributions of Study Patients for Three 
Treatment Factors Which Could Affect the Circulatory 
or Respiratory Systems •  71 
6. Totals of Study Patients and the Activities That 
Were Written as Orders by Surgeons ••••••••••• 73 
7. Frequency Distributions of Control Group Patients 
for Teaching of One or More of the Activities Being 
Studied as Reported by the Nursing Staff •••••••• 94 
8. Means of Categories of Time (in minutes) With 
Patients During the Experimental Preoperative 
Teaching  96 
9. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Feet Exercises  104 
\ 
10. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Leg Exercises  105 
viii 
Table Page 
11. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Deep Breathing  106 
12. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Deep Cough  108 
13. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Support Incision, When 
Indicated or Helpful  109 
14. Comparisons Among the Control and Experimental Groups 
of Patients for the Six Time Categories Indicating 
the Postoperative Day During Which Each Patient First 
Satisfactorily Performed Turning Self in Bed . . . . . 110 
15. Comparisons Among the Control and Experimental Groups 
of Patients for the Seven Time Categories Indicating 
the Postoperative Day During Which Each Patient Was \ 
First Up and Walking   112 
16. Means and Standard Deviations of Control and 
Experimental Groups for the Number of Days From 
Surgery to Discharge  116 
17. Means and Standard Deviations of Control and 
Experimental Groups for the Number of Analgesics 
Given After Leaving Recovery Room Until Discharge 
or Postoperative Day Seven  116 
18. Means and Standard Deviations of Control and 
Experimental Groups for Oral Temperatures as 
Recorded'on the Nursing Unit After Surgery Until 
Discharge or Postoperative Day Seven  119 
ix 
Table Page 
19. Means and Standard Deviations of Control and 
Experimental Groups for Respiratory Rates as 
Recorded on the Nursing Unit After Surgery Until 
Discharge or Postoperative Day Seven  ... 121 
20. General Information of Patients in the Study 
Population . . .     169 
21. Surgical Intervention and Some Treatment Factors 
of Patients in the Study Population . . . . . . . . . . 173 
22. Distributions of Time (in minutes) with Patients 
(N=34) During the Experimental Preoperative 
Teaching and*Some Related Factors ;  .... 178 
LIST OF FIGURES 
Figure Page 
1. Feet ~ Pull and Push  147 
2. Feet - Make A Circle  147 
3. Legs - Pull and Push (Alternately; Bicycling Motions) . 150 
4. An Alternative: Legs - Pull and Push 
(Both legs together).  150 
5. An Optional Method: Legs - Pull and Push; top leg 
only, while lying on side  151 
6. Deep Breathe and Raise Arms While Inhaling  154 
7. An Alternative: Deep Breathe, Hands on Abdomen .... 154 
8. Deep Cough  157 
9. Support Incision  159 
10. Turning Yourself - Back to Side  162 
11. Two Examples of Positions After Turning from Back 
to Side Which Avoid Pressure on Lower Arm  163 
12. Turning Yourself - Side to Back  164 
13. Numbers of Patients in Control (N=34) and Experimental 
(N=34) Groups Who First Demonstrated Satisfactory 
Performance of Activities During the Day of Surgery 
(After Operation)  100 
14. Numbers of Patients on Control (N=34) and Experimental 
(N=34) Groups Who Were Demonstrating Satisfactory 
Performance of Activities During the Day After 
Surgery  100 
ABSTRACT 
Purposes of study: (1) develop a color, silent film of activi¬ 
ties which adult surgical patients may be expected to perform postopera- 
tively, nurse*s guide, and plan for using film, (2) use film and plan 
in preoperative instructions to patients scheduled for common types of 
major surgical treatment, (3) ascertain amount of nursing time involved 
in teaching, (4) compare postoperative performance of activities, as 
evaluated by nursing staff, of patients who received only customary 
nursing care with those who received the experimental teaching, and 
(5) compare characteristics which might represent indicators of 
patients* postoperative physiologic status for both groups. Aims of 
study were methodological and exploratory. Review of literature and 
consultation with experts in related fields was the foundation for pre¬ 
paring the film, guide, and patient-teaching outline. Teaching was 
focused on six postoperative activities: feet exercises, leg exercises, 
deep breathing, deep coughing, support of incision, and turning in bed. 
Potential benefits include helping surgical patients learn how and re¬ 
member to perform activities, and assisting nurses in teaching patients. 
Sixty-eight patients were in the experimental portion which 
contained two groups of patients. The Control Group received customary 
nursing care with no structured teaching. The Experimental Group re¬ 
ceived customary nursing care and experimental teaching by the investi¬ 
gator using the film. Data was collected of nursing staffs' evaluation 
of each patient’s postoperative performance in both groups. Notations 
were kept of time spent in the experimental teaching. Hospital charts 
for all patients were examined for length of hospital stay after 
surgery, analgesics given, first day up and walking, temperature read¬ 
ings, respiratory rates, and reported evidence of complications. 
Analysis of data revealed that evidence exists to indicate that 
patients in the experimental group did demonstrate a higher level of 
ability in performing feet exercises, leg exercises, and deep breath¬ 
ing postoperatively. Postoperative performance of deep coughing, 
support of incision, and turning in bed showed no significant differ¬ 
ence. The .20 level of significance was used in view of the explor¬ 
atory nature of this study. Of items selected as possible indicators 
of patients’ postoperative physiologic status, only the number of 
analgesics administered showed a significant difference. Fewer r 
analgesics were given to patients in the control group. Patients and 
nursing staff seemed to believe that the experimental preoperative 
teaching with the film was beneficial. A tentative conclusion may be 
that such teaching was influential in improving patients' postopera¬ 
tive behaviors. Further investigations seem to be indicated. 
CHAPTER I 
INTRODUCTION 
Expecting patients who have surgical treatment to begin various 
physical activities or exercises very soon after the surgical procedure 
has been recommended in the United States for the past thirty years. 
The majority'of'patients who receive surgical treatment will also be 
out of bed and walking at least-a few steps during the first forty- 
eight hours after'surgery. Several authors state that patients experi¬ 
ence both physiological and psychological benefits as a direct result 
of these aspects of their care, if they are effectively and consis¬ 
tently performed. - 1 Such benefits include a decrease in postoperative 
discomfort, a’ lowered incidence of:postoperative complications, and an 
earlier return^ to the individual's normal state of health. 5 > q 
Certain kinds of surgical treatment may require modifications 
of exactly which activities, how soon, and to what extent they should 
■^Robert D. Dripps and Ralph M. Waters, "Nursing Care of Surgi¬ 
cal Patients I. The 'Stir-up'," The American Journal of Nursing. XLI 
(May, 1941), 530. 
2 
Frederick A. Coller and Marion S. DeWeese, "Preoperative and 
Postoperative Care," Journal of The American Medical Association. CXLI 
(November-5, 1949), 644. ' 
O 
Daniel J. Leithauser, "Early Ambulation," The American Journal 
of Nursing. L (April, 1950), 203. 
^Lillian S. Brunner,.et al., Textbook of Medical-Surgical 
Nursing (2nd ed.; Philadelphia: J. B. Lippincott Co., 1970), p. 134. 
-2~ 
be done following surgery. Individual differences in patients' ill¬ 
nesses and personalities will influence.the details of both medical 
and nursing plans-of careHowever, the basic principles related to 
early utilization of each patient's own abilities in promoting optimum 
functioning of his‘body apply to all patients. 
Common practice within the hospital setting is for the nurse 
to implement instructions written by the physician for the patient's 
care. These orders usually include some mention of the type of physi¬ 
cal activity the-patient is to perform. Activity orders will range 
from a simple "Dangle" or "Up" to a detailed plan for leg and/or arm 
exercises, deep breathing, deep coughing, turning, and degrees of 
ambulatory activity. The nurse's responsibilities in relation to this 
aspect of the patient's care also fluctuate from developing a complete 
plan for progressively helping the patient regain his maximum ability 
in physical movement, to simply seeing that the patient is actually 
correctly performing those activities already delineated by the surgeon. 
Regardless of-such variations, it is the nurse who assists the patient 
to perform these activities. The nurse is responsible for a large part 
of the basic activities even though other departments such as Inhalation 
Therapy or Physical.Therapy may also be providing related care for the 
patientv.r. This-, is true for all patients including those few whose 
surgeons .have-.personally given them some basic instructions about 
their-; activities after surgery. 
-3- 
A persistent difficulty for the nurse is that of effectively 
and efficiently providing for the need to teach patients what they 
need to know. The 1970 report by the National Commission For The 
Study of Nursing and Nursing Education discusses the ’’Scope of Nursing 
Practice” in terms of three categories of nursing actions: 1) Assess¬ 
ment, 2) Intervention, and 3) Instruction.^ "The third category, 
instruction, is so common that it is often overlooked in the rush of 
„6 
day-to-day activities. 
The focus of this study is on patients who are hospitalized 
for common types of surgical treatment, and more specifically on the 
teaching of and performance by patients of selected physical movements 
after surgery. Nursing textbooks are increasingly emphasizing the idea 
that nurses should recognize their patients' needs for teaching and 
become more alert and skillful in meeting these needs. Shafer, in her 
description for preoperative preparation of the patient, states: 
He should be*instructed in any special exercises that he must do 
postoperatively, such as coughing, contracting and relaxing the 
leg muscles, breathing deeply, and turning. 
^Jerome P. Lysaught. Director National Commission for the Study 
of Nursing and Nursing Education, An Abstract For Action (New York: 
McGraw-Hill Book Co., 1970), p. 65. 
Lysaught, p. 67. 
^Kathleen A. Shafer, et al., Medical-Surgical Nursing (4th ed.; 
St. Louis: C. V. Mosby Co., 1967), p. 174. 
-4- 
There is considerable diversity among.textbooks as to the details of 
what should be taught to preoperative patients. 
It has been the investigator’s experience that in many instances 
the surgeon expects the nurse to manage the postoperative exercise 
regime of the patient, yet the nurse does not always do this in a 
consistent and effective manner. This may frequently be due to the 
vagueness of meanings and the diversity of expectations which surround 
the subject. Discussions between nurses and surgeons would seem to be 
essential in answering many of the related questions. Nurses concerned 
about improving the quality of patient care may find some implications 
for their obligations in recent nursing and medical literature. 
One of the nursing journals contains an article written by a 
surgeon who suggestions include "... .a rebirth of physician-nurse 
communications." . He continues "[so I can] . . . communicate again 
with nurses as naturally as I did 15 years ago."^ The 1970 position 
statement approved by the American Medical Association states "OBJEC¬ 
TIVE 5: Delivery'" of medical care is , by its nature, a^ team operation. ^ 
®Roger T..Sherman,. "Total-Patient Care From a Surgeon's Point 
of View."'Nursing Forum. IV (No. 3. 1965), 32. 
^Sherman, p. 32. 
^Committee on Nursing, "Medicine and Nursing in the 1970s: A 
Position Statement," Journal of the American Medical' Association, 
CCXIII (September 14, 1970), 1883. 
-5- 
A study conducted by Pohl collected information from nurses whose areas 
of practice included both the hospital and community. Responses to her 
questionnaire indicated that "The obstacles to teaching which respon¬ 
dents mentioned most frequently were lack of time, heavy work load and 
11 inadequate staffing, and inadequate preparation for teaching." That 
author’s opinion is that 
Only if she sees both the breadth and the limitations of this role 
will her teaching assume its proper place in relation to the total 
field of health education and in relation to the other functions 
of nursing. ^ 
If one assumes that the nurse will be helping the patient learn 
the ways•in which he is expected to perform activities postoperatively 
while'in the'hospital, one may consider how best to do this. By what 
method might the goals of maximum benefits for the patients and the 
most effective use of nursing skills and time be achieved? 
This study grew out of wondering if some ideas and techniques 
from the field of education would be applicable to teaching patients. 
The investigator was particularly interested in the increased rates of 
learning and retention found when motion pictures were used to help 
students learn new concepts. Studies have been reported concerning the 
anxieties of surgical patients, the effects of specific nursing actions, 
11 
Margaret L. Pohl, "Teaching Activities of the Nursing 
Practitioner." Nursing Research, XIV (Winter, 1965), 10. 
^Pohl, p. 10 
-6- 
and the patients' perceptions of their needs. A few research efforts 
have focused on the topic of preoperative instruction for patients. No 
references were located by this investigator which indicated that a 
motion picture had been previously used to teach postoperative activi- 
„ 13, 14, 15, 16, 17, 18 ties to patients. * 
It was for the purpose of exploring factors related to the 
development and use of a film for teaching surgical patients that this 
study was undertaken. Obviously there are many elements which comprise 
the complete picture of each patient's need for preoperative instruc¬ 
tions and interactions with the nurse. This study was restricted to 
one segment of the postoperative activities component of surgical 
patient-teaching. Included was the use of a partial experiment design 
■^-^FajeG. Abdellabr, "Overview of Nursing Research 1955-1968, 
Part I," Nursing' Research, IXX (January-February, 1970), 6-17. 
■^Faje G. Abdellah, "Overview of Nursing Research 1955-1968, 
Part II," Nursing"Research; IXX (March-April, 1970) , 151-162. 
^^Faye G. Abdellah, "Overview of Nursing Research 1955-1968, 
Part III." Nursing Research. IXX (May-June, 1970), 239-252. 
16 
Faye G. Abdellah and Eugene Levine, Better Patient Care 
Through^Nursing-Research"(London:'The Macmillan Company, Collier- 
Macmillan*Limited, 1966). 
■^Leo W; Simmons and Virginia Henderson, Nursing Research: A 
Survey-and-Assessment (New York: Appleton-Century-Crofts,1964), p. 365. 
IQ 
The National Survey of Audiovisual Materials for Nursing 
1968-1969 (New YorkrEducational Services Division, The American 
Journal of Nursing Company, 1970). 
-7 
in an attempt to evaluate a few of the potential benefits for patients. 
The Problems 
General. The general problem area includes: 
1. The need for an agreed upon and consistently used routine 
to serve as a basis for teaching individual surgical patients about 
their postoperative activities. 
2. Identification of what plan is most effective and efficient 
for teaching surgical patients such concepts as leg exercises, deep 
breathing, deep coughing and turning. 
3. Determination of which indices are most useful for the 
purpose of evaluating the effect of such teaching on the patient’s 
behavior and well-being postoperatively. 
Specific. The specific problems considered in this study are: 
1. Could a color, silent film providing visual examples of 
activities to be performed by surgical patients be produced and used 
by a nurse? 
2. What would be the related approximate expenditures of 
money and time? 
3. Will planned patient-teaching by a nurse, the evening before 
surgery, of selected ("stir-up") activities utilizing a motion picture 
result in improved patient performance of these activities postopera¬ 
tively as compared to the performance of those patients who received no 
-8- 
structured teaching of these activities? 
4. Is there any difference between these two groups of patients 
in terms of first day up and walking, length of post-surgical hospital 
stay, number of analgesics received, postoperative temperature readings, 
postoperative respiratory rates, and clinical evidence of postoperative 
complications? 
The Purposes 
1. Develop a silent, color motion picture showing selected 
activities which the adult surgical patient may be expected to perform 
postoperatively and a written nurse’s guide containing suggestions for 
using the film. The potential benefits would include: 
a. Helping surgical patients in learning how and 
remembering to perform these activities. 
b. Assisting nurses in teaching these activities to 
preoperative patients. 
2. Use this motion picture and guide in giving preoperative 
instructions to adult patients scheduled for common types of major sur¬ 
gical treatment other than surgery of the head, neck, extremities, tubal 
ligation, or cesarean section. 
3. Ascertain the 'amount of nursing time involved when using the 
film to help teach patients these activities. 
4. Compare the postoperative performance of these activities, 
-9- 
as evaluated by the nursing staff, of those patients who received only 
the customary nursing care with those who received the experimental 
preoperative teaching using the motion picture. 
5. Compare selected characteristics of both groups which might 
represent indicators of the patients’ postoperative physiologic status. 
Assumptions Upon Which This Study Was Based 
1. It is a nursing responsibility to teach surgical patients 
the ways in which to perform some of the activities which will be ex- 
19 pected of them during the postoperative period in the hospital. 
2. A majority of surgical patients desire to regain their 
optimum state of wellness as rapidly as possible after surgical treat¬ 
ment. 
Hypotheses 
Hypotheses developed in relation to purpose number four are 
.that there is no significant difference between the control and experi¬ 
mental groups in terms of the postoperative day during which the 
patient first demonstrates that he is satisfactorily performing 
1. feet exercises, 
2. leg exercises, 
19 1:7Joyce Travelbee, Interpersonal Aspects of Nursing (2nd ed.; 
Philadelphia: F. A. Davis Co., 1971), p. 199. 
-10- 
3. deep breathing, 
4. the deep cough activity, 
5. support of incision when turning or coughing, if indicated 
or helpful, or 
6. the turning self in bed activity. 
Hypotheses developed in relation to purpose number five are 
that there is no significant difference between the control and experi¬ 
mental groups in terms of the 
7. postoperative day when the patient is first up and walking, 
8. number of days from surgery to discharge, 
9. number of analgesics given after leaving recovery room 
until discharge or postoperative day seven, 
10. oral temperatures as recorded on the nursing unit after 
surgery until discharge or postoperative day seven, 
11. respiratory rates as recorded on the nursing unit after 
surgery until discharge or postoperative day seven, or 
12. postoperative complications experienced until discharge 
or postoperative day, as identified by the attending surgeon. 
Limitations 
1. The small number of patients included in the study. 
2. The short time period that was available for conducting the 
study. 
-11- 
3. Control and experimental patients were unequally distributed 
in categories based on surgical entry site and/or type of surgical pro¬ 
cedure. Pairing of patients was excluded because of this unequal dis¬ 
tribution. 
4. There were many uncontrolled variables, for example, the 
differences in anxiety levels of individual patients, the differences 
in types of surgical treatments experienced by patients, variations in 
the expectations of the nursing staff regarding patients' performance 
of activities, and a wide range of differences in the postoperative 
follow-up nursing care given to patients. 
5. A wide range of differences existed in what constituted the 
teaching component of customary nursing care. 
6. The data collection form used seeks only to identify the 
nursing staff's percentions of the patients' behaviors, not the validity 
of those perceptions. 
7. The data collection forms for.nursing staff's evaluation of 
the patient's performance of activities were incompletely filled out. 
(This occurred even with persistent follow-up by the investigator.) 
Probable influencing factors would include the facts that (1) part-time 
and relief personnel were largely unaware of their role in the study, 
and (2) limitation number eight. 
8. An unexpected change in the nursing unit used for the 
majority of general surgery patients occurred after this study was begun 
-12- 
so that many patients were on nursing units where not all of the per¬ 
sonnel were well-informed about this study. 
9. The possibility of variations in the nursing staff's inter¬ 
pretations of the terms on the data collection form and their percep¬ 
tions of the actual behaviors of the individual patients. 
10. No systematic attempt was made to collect data regarding 
the patient's-evaluation of the experimental preoperative teaching being 
studied. 
11. This study was limited to only facet, i.e., the selected 
activities of the nurse's extensive teaching role and other significant 
interactions with surgical patients. 
Methodology 
This study included the preparation of a motion picture and 
nurse's guide for use in teaching preoperative patients about some of 
their postoperative activities. These teaching aids were then used 
by the investigator to help patients learn how to perform these activi¬ 
ties. An experimental design, conducted in the clinical setting, was 
incorporated into the study. 
The control group received the customary nursing care with no 
structured teaching. The experimental group received the same care and 
also the planned experimental teaching using the motion picture. Data 
was collected regarding the patients' performance of the activities 
-13- 
being investigated as evaluated by the nursing staff. The patients' 
charts were also examined to collect data on length of hospital stay 
after surgery, number of analgesics given, first day up and walking, 
body temperature*readings, respiratory-rates, and notations indicating 
clinical evidence of complications. 
Definition of Terms 
Analgesics: Includes all of the medications actually given to 
the patient, by any route of administration, for the primary purpose 
of relieving pain. 
Control Group: Those patients included in the study who 
received'customary nursing care, including the teaching component of 
customary nursing care, but who did not receive the experimental pre- 
operative teaching. 
Customary Nursing Care: All nursing care given to the patient, 
including explanations and teaching of everything other than the 
selected activities being studied. 
Early Ambulation: The patient is out of bed and walking, with 
or without help, within'the first twenty-four hours after surgery; 
20 21 
subsequently, the patient ambulates at least twice daily. * 
^Collar and DeWeese, p. 644. 
^Leithauser, p. 203. 
-14 
Experimental Group: Those patients included in the study who 
received customary nursing care and the experimental preoperative 
teaching. 
Experimental Preoperative Teaching: Patient-teaching provided 
by the investigator, using the film and guide developed for this study. 
Major Surgery: Defined according to the hospital policy where 
this study was conducted which classified procedures on the basis of 
extent of the surgical intervention. 
Motion Picture: A series of still pictures photographed in 
rapid succession, developed, and then projected under conditions which 
22 
provide the viewer with a visual illusion of motion. The motion 
picture used in this study presented pictures in color and was silent. 
The terms "film" or "movie" are used interchangeably with motion 
picture throughout this study. 
Nursing Staff: All those persons who interacted with hos¬ 
pitalized patients for the purpose of providing nursing care, and 
who made entries in patients' charts, which included their observa¬ 
tions of patients as well as nursing care given. In the hospital 
where this study was carried out, nursing staff included registered 
professional nurses, licensed practical nurses, ward aides (nurse 
“^Amo w. Wittich and Charles F. Schuller .Audiovisual Materials 
(4th ed.; New York: Harper and Row, 1967), p. 419. 
-15- 
aides) , and orderlies. 
Postoperative Day: As used in this study, includes the day of 
surgery as one day, in addition to each of the other postoperative days 
which are conventionally designated as "P.O." or "Postop" days one 
through six. 
Recovery Room: A specialized area in the hospital where 
patients are cared for immediately after surgery and before they are 
returned to the nursing units. 
Satisfactorily Performing: Defined, for purposes of consis¬ 
tency in data collection and analysis, as when the patient performed 
23 24 
an appropriate activity the stated number of times, in a manner 
25 
deemed satisfactory by the nursing staff, and without reminding by 
. * 26 
the nurse. 
^^Patients having lumbar surgery were not expected to "Support 
Incision," or "Turn self in bed"; when surgical entry site was vaginal 
or transurethral, "Support Incision" was not appropriate. 
O / 
q
"At least twice every two hours" for "Exercise Feet," "Exer¬ 
cise Legs," "Deep Breathe," "Deep Cough"; "When coughing or turning, if 
indicated or helpful," for "Support Incision"; and "At least once every 
two hours" for "Turn in Bed." 
25 
"Without reminding" meant that the patient did the activities 
on his own initiative and in a satisfactory manner whether the nurse 
was present or not. 
26 
Experimental group patients were instructed not to "Turn in 
Bed" or "Deep Cough" the first time unless a nurse was with them. 
Thereafter they were to do this themselves unless given other direc¬ 
tions . 
-16- 
Scheduled Surgery: A planned surgical procedure for which the 
patient was scheduled with the hospital admission office before four 
o'clock p.m. of the day prior to the operation. 
Selected Activities Included in This Study: These were defined 
as follows: 
Feet Exercises: Flexion and extension of feet. Also rota¬ 
tion of feet on ankle joint so toes describe a large circle. Both 
movements should be done slowly and firmly to cause definite contrac¬ 
tions of large muscles of the legs. Relax feet and legs. Both feet 
together or each alone, while in bed and/or sitting in or out of bed. 
(Figures 1 and 2, page 147.) 
Leg Exercises: Flexion and extension of both legs. Slide 
feet along bed toward buttocks to tend knees, return legs to horizontal 
and relax. Each leg alternately (like riding a bicycle) or both to¬ 
gether. (Figures 3 and 4, page 150.) 
Deep Breathe: Exhale and place hands on mid-chest. Slow 
deep inhalation consciously expanding abdomen and chest fully while 
extending both arms upward. Slowly exhale as completely as possible by 
compressing both abdominal and chest muscles, while lowering hands to 
rest on mid-chest. Relax. May omit raising and lowering of arms, if 
desired, unless these are ordered by surgeon. (Figures 6 and 7, page 
154.) 
Deep Cough: Place hands on abdomen above umbilicus or in 
-17- 
position to support incision. Deep inhalation, momentary closure of 
glottis, followed by firm contraction of abdominal and chest muscles 
to produce a sudden forceful exhalation through the open mouth, which 
pushes air and/or mucus out of lungs. Relax. (Figure 8, page 157.) 
Support Incision: To be done if indicated or helpful, 
especially when coughing or turning. Thoracic surgery patients (and 
sometimes others) often require the assistance of someone else at first. 
Patients were instructed in use of their hands alone or with a pillow, 
bath blanket, or towel. Patients with an inguinal herniorrhaphy were 
also shown use of thigh for support and were instructed to always 
support their incision when coughing. (Figure 9, page 159.) 
Turn in Bed: (1) From back to side—if turning to right, 
bend knee to place left foot flat on bed. Support incision with right 
arm and hand, grasp side rail with left hand, push with left foot, 
and roll into Sims' position. (2) From side to back—straighten upper 
leg if desired, support incision with arm next to bed, place palm or 
fist of upper arm firmly on the bed and push to roll onto back. 
(Figures 10-12, pages 162-164.) 
"Stir-up": Originally defined by Doctors Dripps and 
Waters to mean that a patient must be turned, must cough, and must 
27 
deep breathe at definite intervals during the postoperative period. 
27 Dripps and Waters, p. 530. 
-18- 
This meaning is expanded for this study to include exercises of feet 
and legs and turning in bed, usually initiated by the patient himself, 
unless such activity is contraindicated by the nature of the surgical 
procedure* or the patient's condition. 
Teach: Used interchangeably with "instruct." Means to 
help another learn and included all activities (formal or informal) 
28 intended to induce learning. 
Teaching Component of Customary Nursing Care: Defined for 
purposes of this study as only that part of teaching related to the 
postoperative activities being studied. This was found to encompass a 
wide range of differences. Included were no instruction at all, limited 
verbal instruction, and a few instances of fairly complete verbal in¬ 
struction with rare demonstrations. No written or pictorial materials 
were provided to patients. The time, i.e., pre- or post-operative, 
when instruction, if any, was given also varied considerably. 
Overview of Remainder of This Study 
The remainder of this study includes the following: Chapter 
II contains a review of some of the pertinent literature, Chapter III 
explains the methodology used, Chapter IV presents the data collected 
28 Pohl, p. 5. 
-19- 
and its analysis. Chapter V is a summary with conclusions and recom¬ 
mendations . Additional information related to this study appears in 
the Appendices. 
CHAPTER II 
REVIEW OF LITERATURE 
The literature was reviewed to locate research and opinions 
considered to be relevant to the general problem area of this study, 
i.e., nursing care of hospitalized adults who require common types of 
scheduled major surgery. The specific intent of this study was to look 
at that segment of the general problem area with regard to preoperative 
patient-teaching by a nurse of selected activities to be performed by 
the patient postoperatively. No previous research or articles were 
found which evaluated, or even mentioned, the use of a motion picture 
in the teaching of preoperative surgical patients. 
Some considerations drawn from four topic areas are reported 
in this chapter: (1) the feelings and concerns of surgical patients 
with related nurse behaviors, (2) reports of three research studies 
about preoperative teaching,-which included activities similar to 
those used in this investigation, (3) the use of motion pictures in 
teaching and its effects on learning and retention, and (4) an explora¬ 
tion of surgical and nursing literature to further establish a basis 
for the content to be included in the experimental preoperative teach¬ 
ing plan, the motion picture, and nurse’s guide. 
Patients’ Feelings. Concerns, and Nurse Behaviors 
Literature in several fields contains explanations of, and 
-21- 
research reports about, what the adult who requires surgical treatment 
experiences mentally and/or emotionally. This area is not the focus 
of investigation in this study, but it is certainly an inseparable 
component of any nursing efforts directed toward patient-teaching. The 
nurse must be cognizant of the patients’ emotional and physical states 
as well as the probable effects of her behaviors. In order for teach¬ 
ing to be useful, it must be presented in the context of what the 
patient wants to know. 
Kutner, in a discussion of patients and surgeons, identifies 
four factors as being emotionally upsetting for patients and explains: 
’’The loss of control over one's personal activities and destiny may be 
the most distressing aspect of surgery to the individual."'*' This idea 
recurs, in conjunction with other factors, such as "fear of pain, of 
the unknown, and of being suddenly dependent, as common in almost every 
preoperative-patient. The greatest fear appears to be that of the 
unknown." Although" diverse methodologies and populations are employed, 
the findings from several other studies agree, in essence, with these 
^Bernard Kutner, "Surgeons and Their Patients: A Study in 
Social Perceptions," Patients. Physicians and Illness, ed. E. Gartly 
Jaco (Glencoe, Illinois: The Free Press, 1958), p. 389. 
2 
Dale C. Levine and June P. Fiedler, "Fears, Facts, and Fan¬ 
tasies About Pre- and Postoperative Care," Nursing Outlook. XVIII 
(February, 1970), 27. 
-22- 
ideas . * 
4, 5, 6 
The work-by Janis, reported in 1958, is frequently cited when 
anxiety is discussed.^ it must be noted that many of his samples were 
small and some of his findings may be subject to question. A subse¬ 
quent research study by Graham and Conley, with a larger sample (N=70), 
does not support Janis' finding that patients anticipating "minor" 
surgery evidenced more apprehension than did those who faced realisti- 
g 
cally hazardous surgery. Johnson, Dobbs, and Leventhal’s study of 
sixty-two females undergoing abdominal surgery reports: 
^June R. Cassady and John Altrocchi, "Patients’ Concerns About 
Surgery," Nursing Research. IX (Fall, 1960), 219-221. 
. 4 
Doris L. Carnevali, "Preoperative Anxiety," American Journal 
of Nursing. LXVI (July, 1966), 1536-1538. 
^Joan S. Dodge, "Factors Related to Patients’ Perceptions of 
■ Their Cognitive Needs," Nursing Research, XVIII (November-December, 
1969), 502-513. 
6 
Sister M. Cashel Weiler, "Post-operative Patients Evaluate 
Pre-operative Instruction," American Journal of Nursing. LXVIII (July, 
1968), 1465-1467. 
^Irving L. Janis, Psychological Stress (New York: John Wiley 
and Sons, Inc., 1958). 
g 
Lois E. Graham and Elizabeth Myers Conley, "Evaluation of 
Anxiety and Fear in Adult Surgical Patients," Nursing Research, XX 
(March-April, 1971), 120. 
-23- 
The findings from this study demonstrate that it is not necessary 
for patients to be frightened and in fact the lower the preopera¬ 
tive fear the more likely there will be low negative emotional 
reactions postoperatively. 
This brings into question the concept that patients will bene¬ 
fit from deliberate attempts to encourage anticipatory anxiety. The 
intention here is not to deny that patients who superficially display 
little or no anxiety need careful evaluation of their needs, but rather 
to suggest that nursing interventions to reduce anxiety may make an 
important contribution to patients' well-being. Certainly there is 
agreement that no "routine" approach will be suitable for all patients. 
An example of only one element, i.e., that females seem more able to 
express anxiety than males, is a finding in two recent studies.^’ ^ 
Janis mentions that surgical patients want to know about the 
12 
type and intensity of sensations which they may expect to experience. 
Q 
^Jean E. Johnson, James M. Dabbs and Howard Leventhal, 
"Psychosocial Factors in the Welfare of Surgical Patients," Nursing 
Research. IXX (January-February, 1970), 28. 
■^John A. Wolfer and Carol E. Davis, "Assessment of Surgical 
Patients' Preoperative Emotional Condition and Postoperative Welfare," 
Nursing Research, IXX (September-October, 1970), 413-414. 
1 1 
•''Stephen M. Weiss, "Psychosomatic Aspects of Symptom Patterns 
Among Major Surgery Patients," Journal of Psychosomatic Research, XIII 
(Pergamon Press, 1969), 111-112. 
12 Janis, p. 374. 
-24- 
He also'reports*that•he found patients experienced less postoperative 
pain when they had been told what to expect before surgery.This 
finding is supported in a study (N=97) by Egbert and others. Pre¬ 
operative and postoperative encouragement and teaching were given to 
forty-six patients by an anesthesiologist. The authors report: "Com¬ 
paring these patients with a control group of patients, we were able 
to reduce the postoperative narcotic requirements by half."^ 
A report by Brambilla of her research with twenty open-heart 
patients presents an idea that may be applicable to other surgical 
patients as well: 
The'basic*concept-which has emerged from this study is that of a 
teaching'plan-which-not*only includes material that nurses think 
patients should'know,'but also one which considers what the 
patients* say they want to know. 
Skipper, Tagliacozzo, and Mauksch, using semistructured interviews with 
eighty-six*patients, report ". . . that communication with physicians 
and nurses was of great importance to the patients. It meant, first, 
13janis, p. 439. 
■^Lawrence D. Egbert, et al., "Reduction of Postoperative Pain 
by Encouragement and Instruction of Patients," New England Journal of 
Medicine, CCLXX (April 16, 1964), 827. 
■^Mary A. Brambilla, "An Investigation of Patients’ Questions 
About Heart Surgery: Implications for Nursing," ANA Clinical Sessions, 
American Nurses’ Association 1968, Dallas (New York: Appleton-Century- 
Crofts, 1968), p. 221. 
-25- 
1 f) 
the securing'of information and second, interpersonal contact," 
Eighty patients who had experienced elective surgery were interviewed on 
the second or third postoperative day in a study reported by Johnson, 
Dumas, and Johnson. These researchers indicate that the nursing be¬ 
haviors 
. . .which apparently helped the patients in this study to cope 
were predominantly of two types: (1) activities which communicated 
understanding and consideration, and (2) explanations about what 
was happening or was going to happen to the patient. 
In view of such research findings, it may be " . . . useful-to 
the nursing practitioner to view all interaction with the patient as 
contributing to the broad process and objectives of teaching- 
18 learning." A substantial portion of patient-teaching by nurses is 
doubtless informal, but nevertheless important and potentially advan¬ 
tageous to patients. An overview of the philosophical background of 
nursing by Redman is concluded with the statement that "... nursing 
. . . involves a helping relationship that has as its objective develop- 
l^James K. Skipper, Daisy L. Tagliacozzo, and Hans 0. Mauksch, 
"What Communication Means to Patients," American Journal of Nursing, 
LXIV (April, 1964), 103. 
■^Jean E. Johnson, Rhetaugh G. Dumas and Barbara A. Johnson, 
"Interpersonal Relations: The Essence of Nursing Care," Nursing 
Forum. VI (No. 3, 1967), 331. 
18 
Barbara Klug Redman, The Process of Patient Teaching In 
Nursing (St. Louis: The C. V. Mosby Co., 1968), p. 4. 
-26- 
19 
ment of independence in the subject." Schulman identifies an impor¬ 
tant aspect of patient care as . . that which centers around the 
process specifically oriented towards having him regain his normative 
healthy state." Rogers expresses a viewpoint typical of other current 
authors when she writes: "Nursing aims to assist people in achieving 
21 their maximum health potential." Whatever the procedural components 
of the nurse-teacher behaviors with patients may be, contemporary 
writers are increasingly emphasizing such concepts as the following: 
... if they [nurses] can help patients feel that here is some¬ 
one who-cares, to whom their feelings and wishes matter, they 
may so restore identity and morale to patients that they get well 
in spite of the usually impersonal regimen of hospital life. 
Dunn suggests that health workers should place more emphasis 
on wellness than sickness and implement this in terms of the body, the 
23 
mind, and the environment. 
19 Redman, p. 2. 
20 
Sam Schulman, "Basic Functional Roles in Nursing: Mother 
Surrogate and Healer," Patients. Physicians and Illness, ed. E. Gartley 
Jaco (Glencoe, Illinois: The Free Press, 1958), p. 530. 
21 
Martha E. Rogers, An Introduction to the Theoretical Basis 
of Nursing (Philadelphia: F. A. Davis Co., 1970), p. 86. 
22 
Sidney M. Jourard, The Transparent Self (New York: Van 
Nostrand Reinhold Co., 1964), p. 151. 
23 
Halbert L. Dunn, High-Level Wellness (Virginia: R. W. Beatty 
Ltd., 1961), pp. 1-3. 
-27- 
Preoperative Teaching Research Studies 
Three studies about preoperative teaching which included activi¬ 
ties similar to those used in this investigation have been reported in 
the nursing literature recently. 
The first of these was conducted by Healy on one nursing unit 
at Good Samaritan Hospital in Phoenix, Arizona. The study population 
consisted of patients admitted to the hospital for elective surgery 
during a four month period. The only mention made as to what kinds of 
surgery were involved is that 152 (of 181 in the experimental group) 
had major abdominal surgery. A specific teaching plan was developed 
to present ". . . deep breathing, turning, coughing, body mechanics, 
and an explanation of the specific procedures expected with the parti- 
,,24 
cular operation. Verbal instructions, demonstration, and practice 
were provided the evening before surgery to each of the 181 patients 
and their families in the experimental group. This was done by one of 
the three registered nurses participating in the study and required a 
minimum of ten to fifteen minutes with each patient. The control group 
consisted of 140 patients who did not receive such concentrated 
instruction. Auxiliary personnel were informed about the details of 
^Kathryn M. Healy, "Does Preoperative Instruction Make A 
Difference?" American Journal of Nursing. LXVIII (January, 1968), 
62-65. 
-28- 
oc 
the instructions given to patients, ^ and postoperative follow-up care 
was an integral part of the basic plan. Also included were exchanges 
of information between the nursing staff and the patient’s surgeon and 
anesthesiologist during the evening prior to surgery for nearly every 
patient.^ 
The results were evaluated by reporting the number of patients 
in each group for the following items: (1) actual discharge date com¬ 
pared with the expected day of discharge, (2) when oral narcotics were 
begun, (3) postoperative complications, thrombophlebitis, and wound 
infections, (4) whether or not a family member stayed in the hospital 
throughout the night. No explanation is given as to how the "expected 
28 day of discharge" was determined. On the basis of the identified 
items, the experimental group appear to have definitely benefited 
from the teaching plan being tested. This author reports additional 
benefits including (1) enthusiasm expressed by patients and families 
about the care received, and (2) improved interest and morale of the 
29 
nursing staff. 
2^Healy, p. 63. 
^^Healy, pp. 66-67 
^Healy, pp. 65-66. 
^Healy, p. 67. 
^Healy, p. 67. 
-29- 
Mezzanotte applied the principles of group instruction to 
teaching preoperative patients admitted to a hospital in Milwaukee, 
30 
Wisconsin for elective abdominal surgery. Detailed plans for instruc¬ 
tion included four areas of information, one of which was "... ac- 
31 
tivity that would promote satisfactory recovery." Groups consisted 
of an average of four patients, and six classes were conducted by the 
researcher herself. Classes were thirty minutes long and held the 
evening before surgery. All patients invited to attend did so, and 
most seemed eager for the opportunity to attend. Exercises were 
explained and practiced during the classes. Each patient was also 
given an instruction sheet to keep for reference. Deep breathing, 
32 
cough, turning in bed, and exercises for feet and legs were taught. 
A semi-structured interview was held by the researcher with 
each patient approximately five to seven days after surgery. Her find¬ 
ings were that all of the patients felt the group instruction was 
beneficial, although individuals indentified different kinds of bene¬ 
fits. There were twenty-three patients in the data-producing sample. 
Fifteen patients commented "... that they had gained the ability to 
30 
Elizabeth J. Mezzanotte, "Group Instruction in Preparation 
for Surgery," American Journal of Nursing. LXX (January, 1970), 89-91. 
31 
Mezzanotte, p. 90. 
32 
Mezzanotte, p. 90. 
-30- 
participate properly in the activity after surgery," and twelve 
33 
mentioned that they "... learned how to improve their recovery." 
An extensive and carefully planned experimental study by 
34 Lindeman and Van Aernam was reported in July of 1971. The nursing 
staff on the surgical units at Luther Hospital in Eau Claire, Wisconsin 
were active participants in all phases of this research. This study 
utilized a teaching plan built around the stir-up routine which con- 
35 
sisted of deep breathing, coughing, and bed exercises. A pilot study 
and classes for all nursing staff were completed before the data 
reported was collected. The administrative, medical, surgical and 
anesthesia staffs, as well as other hospital departments, were all 
involved in the preparatory phase of this study. 
The "3M Sound-on Slide Projector-Recorder" with twenty-four 
36 
slides and messages were used in teaching patients. Teaching was 
done the evening prior to surgery by a registered nurse on the hospital 
33 
Mezzanotte, p. 91. 
34 » Carol A. Lindeman and Betty Van Aernam, Nursing Intervention 
with the Presurgical Patient—The Effects of Structured and Unstruc¬ 
tured Preoperative Teaching," Nursing Research. XX (July-August, 1971), 
319-332. 
35 Lindeman and Van Aernam, pp. 321, 323. 
36 
Lindeman and Van Aernam, p. 323. 
-31- 
staff. Group instruction was frequently used with return demonstra- 
37 
tions on an individual basis. Patients in the study were selected 
on the basis of specific criteria which produced a sample of persons: 
1. Fifteen years and older 
2. Admitted under nonemergency conditions 
3. Scheduled for surgery other than for eye, ear, nose, and 
throat 
4. Scheduled for a general anesthetic 
5. Able to cooperate for the tests of ventilatory function 
6. Not on intermittent positive pressure breathing therapy. 
The control group consisted of 135 patients, and 126 patients were in 
the experimental group. 
The results of statistical analysis for data collected on each 
of the following indices is reported: 
1. Ventilatory Function tests conducted preoperatively the 
evening before surgery, and postoperatively twenty-four 
hours after the start of surgery 
2. "Length of Hospital Stay and Number of Analgesics 
39 
Administered." 
Findings from this study were 
1) the ability of subjects to deep breathe and cough post¬ 
operatively was significantly improved by the structured pre¬ 
operative teaching method; 2) the mean length of hospital stay 
■^Lindeman and Van Aernam, p. 324. 
38 
Lindeman and Van Aernam, p. 321. 
39 
Lindeman and Van Aernam, pp. 324-331. 
-32- 
was significantly reduced by the implementation of the structured 
preoperative teaching method; and 3) there was no differential 
effect upon postoperative need for analgesia. 
All three of these studies report that, in almost all instances, 
patients were pleased" to have received the organized preoperative 
instruction. Patients described various benefits to themselves in 
addition to those specifically employed in the data collection pro¬ 
cedures . 
Lindeman and Van Aernam, and Healy, state that nursing person¬ 
nel found the teaching approaches being investigated to offer definite 
advantages for both patients and themselves when compared with the 
customary inconsistent type of preoperative teaching. These two 
studies also include examples of communication and cooperation between 
physicians and nurses as an integral part of this aspect of patient 
care. 
Motion Pictures: Learning and Retention 
Pictures frequently convey meanings more clearly and easily 
than do words alone. Words used in explanations, whether verbal or 
written, are subject to diverse interpretations. Demonstrations may be 
used to clarify the speakers intended meaning and are certainly useful. 
40 
Lindeman and Van Aernam, p. 332. 
-33- 
When a nurse is attempting to teach "stir-up" activities, some may be 
difficult to demonstrate, e.g., flex and extend legs or turning in 
bed. The ideas that the patient is expected to learn include certain 
movements of the body, therefore motion pictures may be capable of 
portraying this more accurately than still pictures. 
Authors writing in the field of audiovisual instruction have 
compared several types of instructional media with frequently en¬ 
countered objectives for learning. These reports are based on informa¬ 
tion obtained in the school setting, yet it is probable that they have 
implications for teaching patients. 
Inspection of a table prepared by W. H. Allen reveals that of 
six types of instructional media which might be suitable for teaching 
patients (i.e., still pictures, motion pictures, audio recordings, 
demonstration, printed textbooks, oral presentation), only "motion 
pictures" have a rating of "high" (his possible ratings are low, 
medium, or high) for three of the stated six learning objectives. 
Motion pictures are rated "medium" in relation to the remaining three 
objectives. Two (still pictures and demonstration) receive a "high" 
for only one*objective and the remaining three are "medium" for three 
or four objectives with no "high" ratings.^ The objectives listed 
^William H. Allen, "Media Stimulus and Types of Learning," 
Audiovisual Instruction, XII'(January, 1967), 28. 
-34- 
and further discussed-in his report are to learn (1) factual infor¬ 
mation, (2) visual identifications, (3) principles, concepts and rules, 
(4) procedures; (5) to perform skilled perceptual-motor acts; and (6) 
to develop desirable attitudes, opinions, and motivations.^ The 
instructional functions and characteristics of several types of media 
43 
are considered by Kemp. 
The principles of film influence on the viewer have been stated 
by Hoban and Van Ormer on the basis of research studies conducted from 
44 1918 to 1950. These investigators report that "carefully conducted 
research duties [sic] demonstrate that people taught with films are 
better able to apply their learning than people who have had no film 
instruction;Dale has described twelve advantages of films and 
their contributions to learning, and at least five of these seem par¬ 
ticularly relevant to teaching patients. These are that (1) the 
42W. H. Allen, pp. 28-30. 
/ 
^Jerrold E. Kemp, Planning and Producing Audiovisual Materials 
(2nd ed.; California: Chandler Publishing Co., 1968), pp. 34-37. 
44 Carlton W. H. Erickson, Fundamentals of Teaching with Audio¬ 
visual Technology (London: Collier-Macmillan Limited, The Macmillan 
Co., 1965), pp. 55-57. 
45 Edgar Dale, Audiovisual Methods in Teaching (3rd ed.; New 
York: Dryden Press, Holt, Rinehart and Winston, Inc., 1969), pp. 412- 
413. 
-35- 
viewer is provided-with an opportunity to see the motions as a complete 
process, (2) the viewer’s interest is quickly attracted, (3) attention 
is focused on the topic and distractions are reduced or eliminated, (4) 
understanding is not dependent on the viewer’s ability to read or 
hear, and (5) films provide a stable record which can be shown many 
times.^^ That planned use of appropriate motion pictures can pro¬ 
duce a measurable increase in learning for both children and adults has 
been clearly shown by-research. Studies which support the preceding 
statement have been conducted by educational and related organizations, 
private enterprise, the American military, and individuals.^®’ ^^ 
Retention*of information is consistently increased when films 
are used as compared to information presented by verbal means alone. 
46Dale, p. 390. 
47Robert* M. • Gagne', "Learning Theory, Educational Media, and 
Individualized Instruction," To Improve learning. An Evaluation of 
Instructional Technology II, ed. S. G. Tickton (New York: R. R. Bowker 
Co., 1971), pp. 64, 70-71. 
48 
John Flory, "Films for Learning," To Improve Learning, An 
Evaluation of Instructional Technology I, ed. S. G. Tickton (New York: 
R. R. Bowker Co., 1970), pp. 221-223. 
AQ H
^Walter A. Wittich and Charles F. Schuller, Audiovisual 
Materials: Their Nature and Use (4th ed.; New York: Harper and Row 
Publishers, 1967), pp.-401; 405-410; 435-437. 
“^Keith A. Hall, "Research Papers: 1971," Audiovisual Instruc¬ 
tion, XVI (June/July, 1971), 43. 
-36- 
However, many of these studies have been done with school subjects and 
the conclusions do not always indicate if the film was sound or silent, 
or the details of the plan employed for their use.'*'*' The accuracy of 
the ideas which a learner remembers is an important consideration for 
patient-teaching. One report states that when people who had partici¬ 
pated in a discussion (about a subject familiar to them) were asked 
questions two weeks later, only eight percent of the pertinent concepts 
were recalled. In addition, "of the 8% of information recalled, 42% 
of it was wrong." Findings in a study by R. W. Tyler revealed that 
only 28 percent of the information presented verbally was remembered, 
while 78 percent of the information presented verbally, but combined 
53 
with an illustration or picture, was remembered. Ley and Spelman 
discuss the results of several studies which have evaluated various 
factors related to the amount and kinds of information understood and 
remembered by patients. 
Sommer reports that he used silent single-concept film loops 
"’Hlittich, PP* 409-410. 
52 Otis J. McBride, Lecture Series and Workshop Guide ([n.p.]: 
3M Company, Visual Products Department, 1965), Lecture 1 [p. 1]. 
53 
McBride, Lecture 1, [pp. 1-2], 
54 P. Ley and M. S. Spelman, Communicating With the Patient 
(St. Louis: Warren H. Green, Inc., 1967), pp. 58-77. 
-37- 
with three experimental groups (N=42) of eighth and ninth grade students 
to study learning of manipulative skills. "Students in the teacher 
plus film group acquired significantly more skill than did those stu¬ 
dents in either ..." the teacher only or film only groups.These 
findings are consistent with reports of others which convey that show¬ 
ing and explaining together are more effective than either alone. 
Motion pictures are not a panacea. They must be selected in 
view of specific objectives, with an awareness of their limitations, 
and used by a'nurse-teacher who understands how to make this medium 
56 57 
for communication work to its maximum potential. * 
An article published in 1966 gives results from a survey of 
administrators and trustees in more than sixty hospitals. The use of 
nine kinds of audiovisual tools, including motion pictures, were con¬ 
sidered in this report. The findings were that few of the persons 
". . . interviewed had more than a cursory knowledge of the variety of 
audiovisual equipment or of the rapid advances made in audiovisual 
58 
communications in recent years." However, all of those hospitals 
55Hall, p. 43. 
“^Wittich, pp. 436-437. 
^^Redman, pp. 61-63. 
58 James C. McLean, "How to Use Audiovisual Communications," 
Modern Hospital. CVI (February, 1966), 97. 
-38- 
which had utilized one or more of the audiovisual tools in planned 
59 programs considered such efforts to be valuable. None of the programs 
described was directed at teaching patients. 
Frequent references are made to the increasing kinds of equip¬ 
ment which the nurse uses in caring for patients. Educational litera¬ 
ture extolls the advantages for both teacher and student of incorporat¬ 
ing advances in media into learning situations. Perhaps patients and 
nurses could benefit from a judicious utilization of media in the realm 
of patient-teaching. 
I 
Literature'Concerning Stir-Up 
There are at least three foundation articles which have 
appeared in the nursing and medical literature between 1941 and 1950. 
Dripps and'Waters, writing in 1941, focused on the nurse's responsi¬ 
bility for conscientiously implementing the stir-up regimen during 
... gQ 
the postoperative period; The physical and emotional benefits of 
early ambulation for patients were emphasized by Coller and DeWeese in 
"^McLean, pp. 98-100. 
60 
Robert M. Dripps and Ralph M, Waters, "Nursing Care of 
Surgical Patients; Part I. The 'Stir'-up'," The American Journal 
of Nursing. XLI (Hay, 1941), 530. 
-39- 
1949. Leithauser, writing in 1950, believes that "Early ambulation 
has become widely accepted during the past ten years because of its 
62 
value in preventing postoperative complications." He continues: 
6 3 
"Early ambulation after operation is largely a nursing problem." 
This author-presents-a thorough discussion of his views in terms of 
the physiology of■the surgical patient: 
A single-program of planned exercises and early ambulation will 
almost eliminate complications arising in the respiratory, circula¬ 
tory, and digestive systems by establishing a demand for normal 
performance which will create nerve ^mpulses to oppose and conquer 
those originated by surgical trauma. 
Recent surgical and nursing textbooks were examined for infor¬ 
mation relevant to the problems under consideration in this study. In 
addition to material extracted from these sources, references to other 
professional literature written since 1950 are included with the fol¬ 
lowing discussion. 
Surgical textbooks with "surgery" in their titles seem to be 
primarily written to explain surgical pathology and techniques. 
61 
^Frederick A. Coller and Marion S. DeWeese, "Preoperative and 
Postoperative-Care." Journal of the American Medical Association. CXLI 
(November 5, 1949), 644. 
62 
Daniel J. Leithauser, Early Ambulation," The American 
Journal of Nursing. L (April, 1950), 203. 
6 3 
Leithauser, p. 203. 
64 Leithauser, p. 205. 
-40- 
Extensive discussions about preparation of patients for surgery and 
their postoperative care, from the viewpoint of the surgeon, are 
included in several. 
Writing about the principles of postoperative care, R. L. 
Varco states: 
Pulmonary ventilation is promoted by turning the patient at inter¬ 
vals , urging him to cough and breathe deeply .... These 
measures will contribute to a substantial lowering of the inci¬ 
dence of atelectasis and postoperative pneumonia. 
He also supports the recommendation of Kies’ (made fifty years ago) 
for early ambulation, noting that "the only exception may be sepsis . 
Leithauser, Gregory, and Miller (in 1966) express the follow¬ 
ing ideas: 
The only patients we exempt from immediate ambulation are those 
who have uncontrolled bleeding, those who have a history of recent 
coronary occlusion, and those with a nonsustaining blood pressure. 
But we make attempts even with these. / 
The book prepared by a committee of the American College of 
Richard L.-Varco, "Principles of Preoperative and Postopera¬ 
tive Care;"'Christopher*s Textbook-of Surgery,ed. Loyal Davis (7th ed. 
Philadelphia:'W. B. Saunders Coi,•1960), p. 110. 
^Varco, p. 120. 
J. Leithauser, Louis Gregory and Stella M. Miller, 
"Immediate Ambulation After Extensive Surgery," American Journal of 
Nursing, LXVI (October, 1966), 2207. 
-41- 
Surgeons specifically mentions preoperative patient-teaching with 
reference to surgical patients in general, in addition to those having 
chest surgery: 
Many patients are unfamiliar with techniques for achieving optimal 
ventilation and effective coughing. These techniques can be 
taught and practiced preoperatively with more beneficial effect 
than when they are imposed upon a frightened patient in postopera¬ 
tive pain. . . . Patients who are aware of the hazards of 
pulmonary cggplications will cooperate more actively in their 
prevention. 
Postoperative care for patients who have surgery of the abdominal and 
pelvic regions includes: (1) Encouragement of deep breathing and 
coughing, and (2) "The patient is turned frequently, the legs are 
69 
flexed, and bicycling exercises are indicated." The chapter on 
"Postoperative Care of the Gynecologic Patient" contains this state¬ 
ment: 
There is no doubt that the encouragement of active physical exer¬ 
cise with deep breathing, turning in bed and standing up or 
walking, together with the use of foot boards, elastic stockings 
and anticoagulant drugs in selected cases, has reduced the inci¬ 
dence of venous thrombosis and embolism. 
Agreement was found in the medical literature on the point that 
surgical treatment, combined with the use of anesthetic agents, results 
American College of Surgeons, Committee on Pre- and Post¬ 
operative Care, Manual of Preoperative and Postoperative Care 
(Philadelphia: W. B. Saunders Co., 1967), p. 154. 
69 
^American College of Surgeons, p. 348. 
^American College of Surgeons, p. 418. 
^42- 
in some degree of alteration in, and depression of, the body's "normal" 
physiologic state. Exceptions to this may be some of the simple surgi¬ 
cal procedures of short duration and/or employing a local anesthetic 
such as the removal of a sebaceous cyst or wart. There appears to be 
agreement that frequent postoperative deep breathing, coughing, and 
turning are helpful in preventing respiratory complications for a 
large percentage of major surgical patients. 
The question of what measures are most effective in preventing 
deep-vein thrombosis postoperatively is controversial. It is not 
within the province of this investigator to comment on such aspects of 
the question as the use of anticoagulants or other drugs.^ However, 
two articles were found which discuss some of the work done concerning 
the prevention of venous thrombosis and pulmonary emboli that include 
specific plans for some form of exercises involving the lower extremi¬ 
ties. 
In 1951,Leithauser and others described their program of 
postoperative care and the physiology with respect to postsurgical 
increased blood coagulability and venous stasis: 
. . . Hence it follows that vigorous flexion and extension of the 
toes, ankles and knees (in-bed exercises), and frequent walking in 
as brisk a manner as possible will quicken the circulation in the 
^"Prevention of Venous Thrombosis," The Lancet, I (February 
1970), 395. 
-43- 
veins and keep the sticky sludge moving. Thus, any loosely 
attached minute thrombus will be dislodged before the formation 
of a clot of sufficient size to cause fatal pulmonary embolism. 
A study done in London during 1968 points out: 
72 
The true incidence of postoperative deep-vein thrombosis has been 
impossible to estimate because clinical signs can be detected in 
only half the patients so affected, despite the most careful 
examination ... .73 
These researchers conducted an experiment with 132 consecutive 
patients, forty years or more old, scheduled for elective surgery. 
The control group patients were taught leg exercises involving plantar 
flexion against the resistance of a footboard and deep breathing before 
surgery. They wore elastic stockings during surgery. After surgery 
the patients were to move their legs constantly in addition to execut¬ 
ing the planned exercises for five minutes every hour. Patients in the 
test group did not receive this experimental care. All patients were 
evaluated using injected I-labeled fibrinogen as a detector. "The 
incidence of deep-vein thrombosis ... in the control group was 35%, 
and in the test group, 25%.,,7Zh The authors conclude that although the 
72 D. J. Leithauser et al., "Prevention of Embolic Complica¬ 
tions From Venous Thrombosis After Surgery," Journal of the American 
Medical Association. CXLVII (September 22, 1951), 303. 
73C. Plane, V. V. Kakkar and M. B. Clarke, "Postoperative 
Deep-Vein Thrombosis, Effect of Intensive Prophylaxis," The Lancet, I 
(March 8, 1969), 477. 
74 Plane, Kakkar and Clarke, p. 477. 
^44- 
difference was not statistically significant, the fact that there was 
a lower incidence of deep-vein thrombosis detected by this method 
warrants consideration of the possibility that the planned exercise 
regime contributed to this finding. 
Twenty nursing textbooks published since 1964 were selected 
to represent examples ranging from basic nursing care and techniques 
through the more comprehensive medical-surgical texts. Examination 
showed that seventeen contain the subject of preoperative preparation 
of patients. Material presented under this subject heading varies 
widely among the books explored. All provide elements of information 
about nursing care for the immediate preoperative period. Some dis¬ 
cuss additional aspects of nursing care for patients who are in the 
hospital prior to surgical treatment. 
References to explanations or teaching about one or more of 
the kinds of activities being studied are not consistently included 
under preoperative care. At times, these topics appear in the post¬ 
operative care section, often using wording which implies that the 
patient would have been instructed preoperatively. The manner in which 
the patient should perform the activities being considered is not 
clarified in several of the texts. Nine books were found which do 
include substantial attention to the concept of a stir-up regimen. 
-45- 
A comparison of these books revealed that discrepancies exist with 
regard to details concerning the activities to be taught and the 
75 
manner in which they are to be performed by surgical patients. * 
77, 78, 79, 80, 81, 82, 83 
^Jean C. Barbata, Deborah M. Jensen, and William G. Patterson 
A Textbook of Medical-Surgical Nursing (New York: G. P. Putnam’s Sons, 
1964), pp. 82-83, 189-195. 
7 6 
Irene L. Beland, Clinical Nursing: Pathophysiological and 
Psychosocial Approaches (2nd ed.; New York: Macmillan Co., 1970) , 
pp. 249-251, 767-778, 806-811. 
^Lillian Sholtis Brunner et al., Textbook of Medical- 
Surgical Nursing (2nd ed.; Philadelphia: J. B. Lippincott Co., 1970), 
pp. 101-109, 131. 
70 
Shirley Hawke Gragg and Olive M. Rees, Scientific Principles 
In Nursing (6th ed.; St. Louis: The C. V. Mosby Co., 1970), p. 375. 
79 
Dorothy F. Johnston, Total Patient Care: Foundations and 
Practice (2nd ed.; St. Louis: The C. V. Mosby Co., 1968), p. 63. 
on 
Maureen McCutcheon, Care of the Patient With Common Medical- 
Surgical Disorders: A Textbook for Nurses (New York: McGraw-Hill Book 
Co., 1970), pp. 10-12, 300-301, passim. 
81 
Harriet Coston Moidel et al.(ed.), Nursing Care of the 
Patient With Medical-Surgical Disorders (New York: McGraw-Hill Book 
Co., 1971), pp. 484-485. 
82 
Kathleen N. Shafer et al., Medical-Surgical Nursing (4th ed. 
St. Louis: The C. V. Mosby Co., 1967), pp. 194-201. 
83 
''Dorothy W. Smith, Carol P. Hanley Germain, and Claudia D. 
Gips, Care of the Adult Patient: Medical-Surgical Nursing (3rd ed.; 
Philadelphia: J. B. Lippincott Co., 1971), pp. 209-259. 
-46- 
Agreement is evident on two points: (1) the patient should be 
instructed before surgery, and (2) there are physiological as well as 
psychological benefits to patients which result from frequent perform¬ 
ance of stir-up activities. Gragg and Rees explain: 
Preoperative instruction usually should include explanation, 
demonstration, and practice of special exercises, such as deep 
breathing, coughing, turning, relaxing and contracting leg 
muscles, and early ambulation.®^ 
Moidel suggests that "If the patient has been instructed in these 
activities before surgery he will perform them more easily in the 
85 
postoperative period." The afternoon or evening prior to surgery is 
probably the most suitable time for such instruction. Essential in¬ 
formation that is taught too far in advance of need is apt to be for¬ 
gotten. Immediately before surgery the patient’s ability to learn may 
86 
be impaired by medications. Another important consideration is 
pointed out by Brunner: 
The value of preoperative instruction to the patient about to have 
surgery has been recognized and is now substantiated by several 
studies. However, each patient is tgught as an individual; he has 
certain anxieties, needs, and hopes. 
The possible advantages of teaching patients in small groups, 
^Gragg and Rees, p. 375 
®^Moidel, p. 485. 
®®Brunner, p. 109. 
®^Brunner, p. 109. 
-47- 
if combined with individual follow-up, are mentioned by Smith and 
88 Gips. A summary of some research done by social psychologists is 
reported by Ley and Spelman. This work indicates that patients are 
more likely to follow advice when it is presented via a group discus- 
89 
sion rather than individual '’lecture." Redman considered several 
i 
90 
aspects of this teaching technique in her book. Two research studies 
represent applications of this idea to teaching patients before sur- 
91, 92 
gery. 
People need a meaningful reason for learning. This is parti¬ 
cularly true when what they will be doing may be physically uncomfort¬ 
able or painful, as well as difficult to do effectively. There are 
differing opinions about what patients should be told as reasons for 
deep breathing and exercising their feet and legs. For example, "to 
prevent pneumonia and blood clots" is recommended by some authors. 
Others are concerned that the patient should not be unduly alarmed and 
prefer to utilize less potentially frightening ideas. Whatever is 
o o 
Smith and Gips, p. 225. 
^Ley and Spelman, pp. 78-81. 
^Redman, pp. 74-76. 
^Hlezzanotte, pp. 89-91. 
92 
Lindeman and Van Aernam, p. 324. 
-48- 
actually said, the central point is that these activities will help the 
patient recover from surgery more rapidly. They are also something 
which the patient can, in most instances, learn to perform effectively 
93 for himself. In fact, the benefits are greater from active use of 
94 
muscles as contrasted with passive exercises. Deep breathing and 
deep coughing are activities which cannot be done for the patient by 
another person.^ 
Considerable variation occurs in the exact time following sur¬ 
gery when the surgeon prescribes ambulation. This may be related to 
the nature of the surgery, the patient’s condition, or the surgeon’s 
own preferences. "There is seldom any delay, however, in mobilizing 
96 
the patient in bed." In some hospitals, the stir-up is begun while 
the patient is in the recovery room. The general agreement that certain 
activities should be started as soon as the patient is "awake" does not 
include the questions of frequency, method, or how long to continue each 
activity. 
"Exercises of the lower extremities are particularly important 
93 
Smith and Gips, p. 225. 
94 
Mary M. Kelly, "Exercises for Bedfast Patients," American 
Journal of Nursing. LXVI (October, 1966), 2212. 
Q C 
Johnson, Dumas and Johnson, p. 331 
96Beland, p. 250. 
-49- 
in the prevention of venous stasis and should be performed until the 
patient is up and walking about several hours a day." Contraindica¬ 
tions would include some types of vascular surgery and existing 
thrombophlebitis. Slow,firm contractions of the leg muscles causes 
compression of the blood vessels in the leg. During exercise, with the 
attendant contraction and relaxation of these muscles, blood flow is 
increased. Allan, in his reference to surgical patients, points out 
. . . that rest causes stasis of the circulation, loss of muscle 
tonus leading to muscular atrophy, and impaired respiratory and 
renal function. Good function in these systems is essential to 
rapid and complete recovery. y 
Surgical patients also need to have periods of uninterrupted 
rest, and nursing judgment will be required to promote a balance be¬ 
tween exercise and rest."^ In contrast to the viewpoint thirty 
years ago that any exertion by the patient would be harmful, today the 
improved oxygenation and metabolic changes related to appropriate 
^Shafer et al. , p. 198. 
Arthur C. Guyton, Textbook of Medical Physiology (3rd ed.; 
Philadelphia: W. B. Saunders Co., 1966), p. 329. 
^Allan j. Ryan, "The Physician and Exercise Physiology," 
Exercise Physiology* ed. Harold B. Falls (New York: Academic Press, 
1968), pp. 328-329. 
■^^Valentina G. Fischer and Arlene F. Connolly, Promotion of 
Physical Comfort and Safety (Dubuque, Iowa: Wm. C. Brown Co., 
Publishers, 1970), pp. 5-7. 
-50- 
exercise are believed to enhance recovery.'^'*' The physiologic bene¬ 
fits to the circulatory and respiratory systems which result from a 
combination of deep breathing, deep coughing, turning in bed, and 
exercising the extremities, are clearly explained by Secor under 
102 
"Nursing Measures to Prevent Respiratory Complications." 
Deep breathing at frequent intervals is rarely, if ever, 
harmful (unless done too rapidly or frequently so as to constitute 
hyperventilation). "A very deep inspiration is produced by increased 
chest expansion and maximal flattening of the diaphragm." Deep 
inhalations and exhalations require the conscious use of the abdominal 
and chest muscles. Deep breathing is facilitated if the patient is 
placed in a semi-sitting or sitting position because gravity helps to 
decrease the pressure exerted on the diaphragm by the abdominal 
104 
viscera. 
"Coughing may be contraindicated in a few situations, such as 
following brain, spinal, or eye surgery . . . To be beneficial 
■^^•Beland, p. 807 
102 Jane Secor, Patient Care in Respiratory Problems 
(Philadelphia: W. B. Saunders Co., 1969), pp. 86-90. 
•^Secor, p. 87. 
^■^^Secor, pp. 11-12. 
105Shafer et al., p. 196. 
-51- 
in removing mucus, coughing must deep. Deep coughing is not the same 
as simply clearing the throat. It involves a deep inhalation, momen¬ 
tary closure of the glottis, followed by use of the abdominal and chest 
muscles to produce a sudden, forceful expiration through the open mouth. 
Proper support of the incision may promote patient comfort in some 
instances. It is always indicated while coughing for patients who have 
had a herniorrhaphy. 
Using the foregoing and numerous other references, the investi¬ 
gator extracted what might be considered as appropriate and potentially 
beneficial activities for the majority of adult patients experiencing 
common types of major surgery. Definitions and criteria were thus es¬ 
tablished for this study to eliminate inclusion of patients for whom the 
activities selected might be contraindicated, or require modifications 
beyond those specified in the experimental teaching plan. 
The quality of performance of activities by the patient after 
surgery will be influenced by the follow-up nursing care which is pro¬ 
vided. Many variables enter into this, e.g., planning the administra¬ 
tion of analgesics to promote the maximum level of safe comfort in 
relation to the time when the patient is mobilizing himself. A sum¬ 
mary of nineteen investigations is given by Ley and Spelman in a chap- 
ter titled "Do Patients Follow the Advice Given By Doctors?": 
106 Ley and Spelman, pp. 37-44. 
-52- 
The results show quite clearly that many patients do not follow 
the advice given to them. This finding applies to advice given 
on taking medicine and also more complicated advice on dieting 
and feeding and children. 
Two of these studies were conducted with hospitalized patients; the 
remainder were not in a hospital at the time of the study. Even so, 
there would appear to be implications for nursing care when activities 
are being considered that the patient is to initiate himself, and 
which may be difficult for him to perform. Nurses will need to check 
frequently to see if the patient is performing the activities in a 
manner which will obtain the greatest possible benefits. Patients 
often need assistance, encouragement, and reminding to achieve effec¬ 
tive performance. This is a complex area where nursing judgment and 
108 
skill are essential. No attempt was made in this study to deter¬ 
mine the nature of the postoperative nursing care for any of the 
patients in the study population. 
It is possible that preoperative patient-teaching may result 
in more efficient utilization of nursing time because less repetition 
of instructions will be required postoperatively and patients will 
understand what is expected of them. Fundamental to this study are 
the concepts that a patient*s anxiety level is lowered, fears are 
lO^Ley and Spelman, p. 41. 
■^^Fischer and Connolly, pp. 5-7, 26, 31-35. 
-53- 
reduced, morale is better, and performance of activities is improved 
if appropriate instruction is provided before surgery. 
Chapter III describes the methodology used in this study. It 
includes details of the study population chosen as well as an outline 
of the preoperative patient-teaching plan used. Chapter IV contains 
the data collected and its analysis. A summary of the study, conclu¬ 
sions, and recommendations for further study are presented in Chapter V. 
CHAPTER III 
METHODOLOGY 
Introduction 
The first part of this chapter presents information about the 
development of a motion picture and nurse's guide for use in the 
planned experimental teaching of preoperative patients. Next, the 
method of selection and characteristics of the population chosen for 
the study are described. Explanations of the patient-teaching plan, 
data collection tool, and other components of data collection are 
included. 
The aims of this study were both methodological and explanatory. 
A partially experimental design of collecting information was chosen. 
The general area involved is that of nursing practice.^" Surgical 
nursing units in a general hospital served as the research setting. 
The conditions under which the study was conducted permitted very 
limited control of variables. The focus was on looking at an idea 
which might have implications for improving nursing practice as it is 
related to the care of patients hospitalized for surgical treatment. 
Human elements occurring in the clinical situation played an integral 
part in the subject being considered. 
Jeanne Phillips and Richard Thompson, Statistics For Nurses 
(New York: The Macmillan Co., 1967), p. 5. 
-55- 
Some authors have applied the term "action oriented research" 
3 4 
or simply "action research" to situations of this nature. ’ Corey 
discusses problems encountered when research in education is conducted 
within the complicated psycho-sociological environment of an actively 
functioning school. He suggests: 
Because of the multiplicity of variables involved, the research is 
often lacking in precision. The results, however, have meaning 
for practice because they derive from an inquiry carried out in a 
real situation.^ 
It is possible that an analogy exists with patients who are hospital¬ 
ized. One of the most difficult problems in research concerned with 
clinical nursing is to find "... meaningful criterion measures . . . 
This study included the preparation of a motion picture and 
nurse’s guide for its use in teaching preoperative patients about some 
o 
Claire Selltiz et al., Research Methods in Social Relations 
(rev. ed.; [New York]: Henry Holt and Co., Inc., 1959), pp.457-466. 
3 
Burton Meyer and Loretta Heidgerken, Introduction to Research 
in Nursing (Philadelphia: J. B. Lippincott Co., Inc., 1959), pp. 72-73, 
210, passim. 
^Stephen M. Corey, Action Research to Improve School Practices 
(New York: Bureau of Publications, Teachers College, Columbia Uni¬ 
versity, 1953), pp. 143-144, passim. 
^Corey, p. 143. 
fi 
Barbara A. Johnson, Jean E. Johnson and Rhetaugh G. Dumas, 
"Research in Nursing Practice: The Problem of Uncontrolled Situational 
Variables." Nursing Research. IXX (July-August, 1970), 337. 
-56- 
of their postoperative activities. An outline for patient teaching of 
selected activities was developed. The motion picture was then used by 
the investigator to help patients learn about the manner in which they 
would be expected to perform these activities. A 202-bed general 
hospital in Montana was the clinical laboratory for this study. Five 
weeks were devoted to refining an experimental teaching plan that would 
be acceptable within the framework of this hospital. During this time 
the motion picture was also filmed, developed, edited, and prepared for 
use with patients. 
All patients scheduled for surgery between February 11, 1971 
and March 11, 1971 were screened for possible inclusion in the study 
population. A total of sixty-eight patients met the predetermined 
criteria and were included in this study. The first thirty-four became 
the control group; the next thirty-four were placed in the experimental 
group. The control group received the customary nursing care with no 
structured teaching. The experimental group received the same nursing 
care and also planned teaching using the motion picture. All of the 
teaching interactions using the film were conducted by the investigator. 
A data collection tool developed by the investigator was used 
to collect data regarding (1) the patient’s performance of the activi¬ 
ties being investigated as evaluated by the nursing staff, and (2) the 
teaching component of customary nursing care for the control group. 
In addition, patients’ charts were examined at least three times 
-57~ 
(i.e., (I) the afternoon or evening prior to surgery, (2) the evening 
of the day of surgery, and (3) after postoperative day seven and/or 
discharge) to extract relevant data. Data collection continued through 
March 18, 1971 to include postoperative day seven and/or the discharge 
date for patients included in the study. 
Many aspects of the exploratory portion of this study and pre¬ 
liminary work were underway simultaneously. The subjects in this 
chapter are not necessarily presented in chronological order. Repeti¬ 
tion of information is eliminated whenever possible. Most of the 
topics are interrelated and some of the components properly belong 
under several headings. 
Development of Content for Film and Guide 
Tentative plans for the content of the film and guide were 
developed by the investigator. The activities to be included in the 
film and the techniques for performing them were evolved on the basis 
of information compiled from a variety of sources. The objective was 
to extract what might be considered as appropriate and potentially 
beneficial activities for the majority of adult patients experiencing 
common types of major surgery. 
An outline for the content of the film and nurse’s guide was 
formulated. This outline was then reviewed by a panel of experts 
composed of members of the nursing and surgical staffs at the hospital 
-58- 
where this study was carried out. Questions considered by these persons 
which were essential for planning preoperative patient-teaching are 
listed in Appendix A on pages 141-142. Revisions and additions were 
made to concur with the methods which were the most consistently agreed 
on for this hospital. Interviews were held with the persons in charge 
of the Operating Room, Recovery Room, Anesthesia, Inhalation Therapy, 
and Physical Therapy departments. These interviews helped to coordi¬ 
nate items in the experimental teaching plan with the usual plans of 
those departments for surgical patient care. 
Planning and Production of the Film 
One of the central objectives for the experimental preoperative 
teaching was to help patients learn about the manner in which they 
would be expected to perform selected activities after surgery. A si¬ 
lent, color motion picture, combined with verbal interactions and 
7 8 practice supervised by a nurse seemed to be the method of choice. * 
To the investigator’s knowledge there is no film in existence for the 
purpose of teaching patients about their postoperative activities. 
Effort was devoted to learning about planning and producing a suitable 
^Edgar Dale, Audiovisual Methods in Teaching (3rd ed.; New York: 
Dryden Press, Holt, Rinehart and Winston, Inc., 1969), pp. 390-417. 
g 
Jerrold E. Kemp, Planning and Producing Audiovisual Materials 
(2nd ed;;California: Chandler Publishing Company, 1968), pp. 4-38. 
-59- 
film, as the investigator had no previous experience in these matters. 
Instruction and advice were provided by a faculty member of the College 
of Education at Montana State University. 
9, 10 
A content script and storyboard planning cards for the 
actual filming of the motion picture were prepared by the investigator. 
Technical assistance regarding specifications such as camera angles, 
distances, lighting, and use of a movie camera was obtained from two 
experts in the field of educational media production. These persons 
were faculty members of Montana State University and Eastern Montana 
College respectively. Size super-8mm film was selected as being best 
suited for use by a beginner in movie making. Super-8ram also met 
additional requirements related to the intended use of the movie (e.g., 
11 12 low cost and easy portability of the projector). * The setting of 
a hospital room required that the movie be made indoors using movie 
lights. Color film was chosen instead of black and white to increase 
Movies With a Purpose ([New York]: Motion Picture and Educa¬ 
tion Markets Division, Eastman Kodak Company, [1970]), pp. 2-27. 
10Kemp, pp. 39-61. 
11 
John Florey, "Films for Learning," To Improve Learning, An 
Evaluation of Instructional Technology I, ed. S. G. Tickton (New York: 
R. R. Bowker Co., 1970), pp. 223-224. 
12 
Louis Forsdale, "8mm Film in Education Status and Prospects- 
1968,"To Improve Learning. An Evaluation of Instructional Technology I. 
ed. S. G. Tickton (New York: R. R. Bowker Co., 1970), pp. 232-239. 
-60- 
the attention attracting potential and realism of the finished movie. 
The film used was Kodachrome II Movie Film, Type A, in a super-8mm 
cartridge, as the original intent was to produce only one film for 
projection. 
13 
The final scene-by-scene filming script was created after the 
details concerning the activities to be included were established. Per¬ 
mission was granted by the hospital where this study took place to use 
an unoccupied, but otherwise typical, patient room and furnishings for 
the "shooting" of the film. The "patient" shown in the film was a 
graduate student who is a registered nurse. Considerable time, effort, 
and patience were graciously provided by the many persons involved in 
all the steps that finally culminated in the finished motion picture. 
Equipment used by the investigator for the filming of the movie, 
title making, and later projection was the property of Eastern Montana 
College. A Bell and Howell 430 Autoload Super-8mm camera served to 
make both the scenes and the titles. This camera has a reflex view¬ 
finder; therefore the cameraman is able to see the same picture as the 
one which is recorded on the film. A zoom lens permitted variations in 
14 focal length from wide angle to telephoto. The zoom lens was essen¬ 
tial to make close-up scenes and titles. Close-up scenes were included 
•^Kemp, pp. 39-55. 
■^Kemp, pp. 190-191. 
-61- 
to concentrate the viewer's attention on specific movements being demon¬ 
strated in the movie. Built-in features of the camera were an automatic 
light exposure meter and a rangefinder coupled to the lens. The dis¬ 
tance from subject to film was carefully measured for each scene as a 
basis for setting the lens. A tripod was used to support the camera 
and insure recording of sharp images. Two off-camera photoflood lights 
with ColorTran lamps supplied the illumination. There were positioned 
15 16 
as "main" and "key" lights. * Filming (and later projection) was 
at eighteen frames per second as is common for a silent motion picture 
when using super-8mm film. 
After filming, the film was sent to a commercial processing 
laboratory for development. Subsequent selection of the desired foot¬ 
age, editing, and splicing were performed by the investigator."^ In 
addition to the main title, separate titles for each different activity 
had been prepared. These were placed before the scene depicting the 
activity to be taught. Two seconds of black film space were included 
at the end of each activity shown. This would serve to signal the 
nurse using the film and permit time for the projector to be stopped. In 
this way, verbal interaction with, and supervised practice by, the 
•^Movies With A Purpose, pp. 8-10. 
^Kemp, pp. 72-86. 
■^Kemp, pp. 206-210. 
-62- 
patient could immediately follow each topic. Final total running time 
for the entire film was approximately seven minutes. 
The completed version of the movie was placed on a reel designed 
to fit into a plastic cartridge. The cartridge chosen does not require 
special equipment for loading and permits the reel to be easily removed 
for use in a different projector (reel-to-reel) if necessary. The pro¬ 
jector selected was the Kodak Ektagraphic 120 with features deemed 
essential for patient-teaching. These included (1) ability to stop the 
film at any point, (2) instant rewind of a portion if desired, (3) 
unobtrusive movement of a section of the film on through to the next 
scene without distracting the patient by showing any section not appli¬ 
cable to him, and (4) automatic threading and rewinding at the end to 
save time for the nurse. A small, lightweight screen produced by 
Hudson Photographic Industries permitted both projector and screen to 
be placed on a standard overbed table. This arrangement produced an 
easily observed, clear picture regardless of whether the patient was in 
bed or a chair. A list of basic equipment needed for super-8mm film 
production and projection with cost estimates is shown in Appendix B, 
pages 166-167. 
Study Population 
Patients included in both the control and experimental groups 
for this study were deliberately selected on the basis of the following 
-63- 
criteria: 
1. Scheduled for a common type of major surgery, as defined 
for this study. 
2. In the hospital the evening before surgery. 
3. Eighteen years of age or older. 
4. Sufficiently alert to be oriented to time and place. 
5. Capable of understanding and following simple directions in 
English. 
6. Functional vision either with or without corrective lenses, 
i.e., able to distinguish people and objects within eight feet of them¬ 
selves . 
7. Permission from the patient’s surgeon for the patient to be 
included in the study (required for the experimental group only). 
A list of common operations published in 1966 by Modern Hospi¬ 
tal,1^ in combination with the itemized classification of surgical 
procedures as "major" or "minor" for the hospital involved, was used as 
a guide for the first criteria. Patients scheduled for surgery involv¬ 
ing the head, neck, extremities, tubal ligation, or cesarean section 
were excluded. This was done to produce a more homogenous sample and 
for convenience. The activities being studied are applicable to 
■^Robert S. Meyers, "Here Are 50 Most Common Operations," 
Modern Hospital, CVI (January, 1966), 122. 
64- 
patients who have a cesarean section, but these patients usually are 
cared for on an obstetrical rather than a surgical nursing unit. Pa¬ 
tients requiring orthopedic surgery would often require some specific 
modifications of those activities which involve the extremities and 
turning. 
The hospital participating in this study was a voluntary com¬ 
munity hospital providing surgical services for a variety of conditions 
including general surgery, urologic, gynecologic, and thoracic, as well 
as orthopedic, neurologic, pediatric, and obstetrical. Scheduled sur¬ 
gery was performed each day from Monday through Friday between the hours 
of seven a.m. and three p.m. Permission was granted for the investiga¬ 
tor to review the list of all patients scheduled for surgery. 
The investigator established four o’clock p.m. of the day prior 
to surgery as the latest a patient could be scheduled and still be con¬ 
sidered for this study. This was selected because (1) patients were 
usually scheduled before that time, and (2) time was required to talk 
with the patient’s surgeon whenever the investigator either did not 
already have his permission, or if some question needed to be discussed. 
Only two potential candidates were excluded because the researcher was 
unable to talk with the surgeon before surgery. One of the twenty-nine 
surgeons interviewed had previously requested that his patients not be 
involved in the study which precluded the inclusion of two others. 
Charts of all patients considered to be possible candidates for 
-65- 
inclusion in this study were examined by the researcher. The nursing 
staff was consulted for an opinion when necessary to clarify information 
related to the selection criteria. The investigator did not personally 
interact with any of the patients in the control group. Patients in 
the experimental group were seen when being taught by the investigator. 
Of the 319 patients scheduled for surgery (excluding emer¬ 
gencies and patients added after four o’clock p.m. of the day prior 
to surgery), seventy initially appeared to meet the foregoing criteria. 
Two of these were omitted following surgery because the actual surgery 
performed for one patient was not common. The other patient became 
quite disoriented after surgery and was cared for by private duty 
nurses. Thus, the sample population for this study was drawn from 
those patients who were scheduled for surgery during the four weeks 
from February 11 through March 11, 1971. The total sample actually 
selected was sixty-eight patients. 
The two groups appeared to be generally similar for the 
characteristics shown in Table 1 on page 66. There were five more 
males and five fewer females in the control group as compared with the 
experimental group. Patients in the total study population had an age 
range of from twenty to eighty-three years. The mean ages were 51.882 
years for the control group and 56.352 years for the experimental group. 
The difference in mean age between the groups was 4.470 years. With 
regard to previous hospital admission or previous surgery, the dif- 
-66- 
Table 1. Frequency Distributions of Some Characteristics of Patients 
in the Study Populationa 
Groups 
Characteristics Control 
N=34 
Experimental 
N=34 
Sex 
Male 24 19 
Female 10 15 
Age Range (in years) 20-80 21-83 
Age Groups (in years) 
20-41 9 4 
42-63 14 16 
64-85 11 14 
Previous Hospital Admission 
Yes 26 24 
No 8 10 
Previous Surgery 
Yes 17 20 
No 17 14 
aSource: See Appendix D, pages 169-172. 
-67- 
ferences were two and three respectively between the two groups. 
Many variables could affect a patient's ability to perforin the 
activities being studied. No attempt was made in this study to evaluate 
factors such as anxiety, fear, or emotional status. Information about 
six physical factors was available for all study patients and is shown 
in Table 2. None of the patients in the control group had severe un<- 
corrected hearing loss, although two in the experimental group did. In 
the total study population, there were six patients with emphysema and 
Table 2. Frequency Distributions for Some Physical Factors Which Might 
Affect Performance of Activities by Patients in the Study Population3 
Factors Which Might Affect Performance 
of Activities 
Control 
N=34 
Experimental 
N=34 
Severe Uncorrected Hearing Loss 0 2 
Emphysema 2 4 
Asthma 1 2 
Arthritis 1 1 
Pain in Extremities (Other than 
Arthritis) 1 1 
Unable to Move an Extremity 1 1 
aSource: See Appendix D, pages 169-172. 
-68- 
three with asthma. Two patients (one in each group) appeared with each 
of the following: arthritis, pain in an extremity (other than 
arthritis), and inability to move an extremity. 
The surgical entry site and/or type of surgical procedure may 
affect the patient's ability or willingness to move. These items also 
determine which activities are appropriate for each patient. Catego¬ 
ries established by the investigator, and the main procedures performed 
for patients in this study were: 
Thoracic: Thoracotomy; lobectomy; thoracotomy with resection 
of mediastinal tumor or biopsy of mediastinal mass. 
Lumbar: Excision of lumbar disc; excision herniated nucleus 
pulposus; laminectomy; laminotomy; hemilaminectomy 
and spinal fusion. 
Upper Abdominal: Gastrectomy; gastric resection; vagotomy; 
liver biopsy; cholecystectomy; cholecystectomy with 
common duct exploration; exploratory laparotomy. 
Lower Abdominal: 
(1) Inguinal herniorrhaphy. 
(2) Abdominal hysterectomy with or without Marshall 
Marchetti; salpingectomy; oophorectomy; lower right 
colon resection; lower left colon resection; 
appendectomy; pelvic laparotomy. 
Pelvic (requiring the patient's legs to be elevated in stirrups 
during surgery): 
(1) Vaginal hysterectomy; anterior-posterior repair. 
(2) Transurethral resection of the prostate. 
The number of patients in both the control and experimental 
groups (see Table 3, page 69) was the same for thoracic and upper 
abdominal, and nearly the same for inguinal herniorrhaphy and pelvic. 
-69- 
Table 3. Frequency Distribution of Control and Experimental Patients 
by Categories Based on Surgical Entry Site and/or Type of Surgical 
Procedure3 
Surgical Entry Site and/or Type 
of Surgical Procedure 
Control Experimental 
Thoracic 2 2 
Lumbar 6 2 
Abdominal 
Upper 5 5 
Lower 
(1) Inguinal Herniorrhaphy 3 4 
(2) Hysterectomy and Lower Abd. 
Internal Structures 4 9 
Total 12 18 
Pelvic (requiring patient's legs to be 
elevated in stirrups during surgery) 
(1) Vaginal: Hysterectomy and/or 
Anterior-Posterior Repair 2 2 
(2) Transurethral Resection of 
Prostate (TUR) 12 10 
Total 14 12 
Total 34 34 
aSource: See Appendix E, pages 173^177. 
-70- 
Wide r differences existed for two categories: lumbar (six in control 
group, two in experimental group) and abdominal hysterectomy and lower 
abdominal internal organs (four in control group, nine in experimental 
group). 
Twenty-one patients received a general anesthetic, and thirteen 
patients received either a spinal or epidural anesthetic in both groups. 
The duration of the anesthetic ranged from forty minutes to four hours 
and fifty minutes. Table 4 shows the number of patients who were in 
Table 4. Type of Anesthetic Received and Duration of Anesthesia in The 
Operating Rooma 
Group 
Control 
N=34 
Experimental 
N=34 
Type of Anesthetic 
General 21 21 
Spinal or Epidural 13 13 
Length of Time Anesthetized in the 
Operating Room 
Less than 1 hour 7 5 
1 - <2 hours 18 19 
2 - <3 hours 5 9 
3 - <4 hours 2 1 
4 hours or more 2 0 
aSource: See Appendix E, pages 173-177. 
-71- 
each. of five hour categories for this factor. Slightly more than fifty 
percent of each group were anesthetized from one to two hours. 
Data was collected for three kinds of treatments which could 
affect the circulatory or respiratory systems. Table 5 shows that none 
of the patients in the total study population received anticoagulants 
postoperatively. Four patients in each group received intermittent 
positive pressure breathing treatments in relation to their 
surgical experience. Elastic support stockings were ordered for three 
and six patients in the control and experimental groups respectively. 
Table 5. Frequency Distributions of Study Patients for Three Treatment 
Factors Which Could Affect the Circulatory or Respiratory Systems 
Treatment Control 
N=34 
Experimental 
N=34 
Anticoagulants (Postoperatively) 0 0 
Elastic Support Stockings 
N  31 28 
Yes 3 6 
Intermittent Positive Pressure 
Breathing Treatments 
No 30 30 
Yes 4 4 
Before Surgery Only 1 0 
After Surgery Only 3 3 
Both Before and After 0 1 
-72- 
Inspection of Table 6 on page 73 reveals that the patient's 
surgeon wrote an order pertaining to two or more of the activities 
shown (which are similar to those being studied) for fourteen of the 
sixty-eight patients. Comments from surgeons during interviews with 
the researcher revealed a wide range of attitudes. A few seemed to 
feel that having patients do these things was (1) "... okay, but not 
always necessary," or (2) "necessary only if I write an order because 
I tell my patients what to do." The importance of mutual surgeon and 
nurse planning for certain specific procedures and patients was 
emphasized by some. Typical ideas were (1) "Yes, I think it is a 
good idea to have patients learn about and do all of that (i.e., the 
stir-up)," and (2)"A11 of my patients should be doing those (i.e., 
the activities on the experimental teaching outline), whether I write 
an order or not." 
The patients who participated in this study may be considered 
typical of adult patients having common types of scheduled major sur¬ 
gery at the hospital where this study was conducted. This study popu¬ 
lation might also be representative of other surgical patients in terms 
of the characteristics specified for this study. However, the number 
of patients involved was too limited to permit conclusive generaliza¬ 
tions . 
Table 6. Totals of Study Patients and the Activities That Were Written 
As Orders By Surgeons 
Activity Ordered 
Control Experimental 
Group Group 
(N=34) (N=34) 
All Patients 
in Study 
(N=68) 
Actual Number of Patients 
Involved3 8 6 14 
Deep Breathe 8 6 14 
Cough 3 4 7 
Move Legs, or Exercise Legs 6 4 10 
Arm Exercises 3 1 4 
Turn Frequently With or 
Without Help 3 5 8 
aFrom two to four of the activities listed were ordered for 
each patient. 
Experimental Preoperative Teaching Outline 
For purposes of the planned experimental preoperative teaching 
the interactions between all of the patients in the experimental group 
and the researcher were kept as uniform as possible. The details of the 
plan itself, including the film, narration, guide, and behaviors of the 
investigator while teaching, were built on principles and theories 
drawn from several sources. 
-74- 
19, 20, 21 References pertaining to nurse 
and patient communications were also utilized. 22, 23, 24, 25, 26, 27, 
28, 29 
19 *• Robert M. Gagne> "Learning Theory, Educational Media, and 
Individualized Instruction," To Improve Learning. An Evaluation of 
Instructional Technology II, ed. S. G. Tickton (New York: R. R. Bowker 
Co., 1971), pp. 61-74. 
20 Lee J. Cronbach, Educational Psychology (2nd ed.; New York: 
Harcourt, Brace and World, Inc., 1963), pp. 404, 473, 525. 
21 Ernest R. Hilgard and Gordon H. Bower, Theories of Learning 
(3rd ed.; New York: Appleton-Century-Crofts, Educational Division, 
Meredith Corporation, 1966), pp. 534-536; 545-551; 562-565; 582-583. 
22 Frances Storlie, "A Philosophy of Patient Teaching," Nursing 
Outlook, IXX (June, 1971), 387-389. 
23 P. Ley and M. S. Spelman, Communicating With the Patient 
(St. Louis: Warren H. Green, Inc., 1967). 
24 Eleanor C. Lambertson, "Nurses Must Be Teachers and Must 
Know These Principles," Modern Hospital. CX (February, 1968), 126. 
25 Barbara Klug Redman, The Process of Patient Teaching in 
Nursing (St. Louis: The C. V.Mosby Co., 1968), pp. 4, 7-8, 102-103. 
26 Garland K. Lewis, Nurse-Patient Communication (Dubuque, 
Iowa: Wm. C. Brown Co., 1969), pp. 23-25, 31-32. 
27 
'Lois A. Monteiro, Notes on Patient Teaching - A Neglected 
Area," Nursing Forum, III (No. 1,1964), 26-33. 
28 Christine MacArthur, "We Teach - Do Our Patients Learn?" 
The Canadian Nurse, LV (March, 1959), 205-210. 
29 Joyce Travelbee, Interpersonal Aspects of Nursing (2nd ed.; 
Philadelphia: F. A. Davis Co., 1971), pp. 189-191, 197. 
-75- 
The final form of the nurse’s guide was developed as a corol¬ 
lary of the film and work done for the study. Drawings included in 
the guide were made by a faculty member of Montana State University, 
College of Education. The guide appears as Appendix A on pages 138- 
165. It contains additional information, including potential benefits 
of each activity and drawings of film scenes. 
I. Basic Plan 
A. Timing of Instruction: 
Teaching is to be done the evening before surgery 
in the patient’s own room, after supper and before 
bedtime, and correlated with any other preparations 
which were planned. 
It would be desirable to have family present during 
instruction, as they could thus become informed about 
activities and might be able to offer appropriate 
support and encouragement to the patient postopera¬ 
tive ly. However, limited visiting hours meant that 
patients might prefer to have instruction given when 
family was not present. 
B. Initial Contact With Patient: 
"Hello (address patient by name), I’m (nurse's 
name), one of your nurses. I have a movie to show 
you about what you will be doing after your surgery 
-76- 
tomorrow. Do you have time to see it now?" If there 
were visitors present, or if the patient was doing 
anything which he might prefer not to interrupt, 
. . or would you like for me to come back later?", 
was added. 
When another patient was in the same room, he was 
also greeted and treated with consideration. Some¬ 
times he was included, or the curtains were drawn, 
depending upon what seemed most appropriate. 
C. Needs for Other Nursing Care and Information: 
Almost all of the patients were visited by their 
head nurse or team leader before the teaching about 
activities was done. This provided an opportunity 
for the exchange of information other than that re¬ 
lated to the activities being studied. 
The investigator relayed all applicable patient re¬ 
quests and observations which occurred during her 
interactions with the patient to the regular nursing 
staff. 
D. Reason for Doing the Activities Postoperatively: 
"Doing these regularly will help you feel better 
sooner after your surgery," or ". . . get well 
faster." 
-77- 
E. Frequency: 
Instruct patient to do each activity consistently 
every two hours, except when asleep at night, unless 
otherwise ordered by his surgeon. Some surgeons 
ordered activities to be done every hour and/or 
throughout each twenty-four hour time period for the 
first few days. 
(Number of times to do each activity is given with 
the information about each scene in the film.) 
Patients were instructed to continue regular per¬ 
formance of activities until they were up and walking 
about for several hours each day. 
F. Location of Patient and Preoperative Practice: 
1. If in bed: 
a. All appropriate activities were practiced. Bed 
was flat, or nearly flat, for all activities 
except "Deep Breathe" and "Deep Cough." ("Sup¬ 
port Incision" was combined with both "Deep 
Cough" and "Turning Yourself.") 
b. Bed was changed to sitting or semi-sitting 
position for practice of "Deep Breathe" and 
"Deep Cough." 
2. If in chair at the time of instruction (unless the 
-78- 
patient chose to get into bed and practice): 
a. Practice of the "Legs-Pull and Push" was per¬ 
formed in a modified manner. 
b. "Turning Yourself" was not practiced at this 
time. 
c. It was suggested to the patient that he 
practice these when he got into bed. 
XI. The Motion Picture, Methods, and Narration Ideas: 
A. Title of film: "YOU AFTER SURGERY: IMPORTANT 
ACTIVITIES" 
B. Actual showing time for entire film: seven minutes. 
C. Stop film after patient watches each activity, have 
patient practice and verify that he can correctly 
perform each of the activities. Encourage and offer 
suggestions for improvement whenever indicated. State 
the number of times to do each exercise and repeat 
"... every two hours," or ". . . every hour." 
Answer any questions (verbal or non-verbal). Add any 
special instructions. 
D. Film Titles, Scenes, and Activities Shown (including 
individualized details related to variables such as 
the nature of the planned surgical procedure): 
1. First scene (after main title) is patient in bed 
-79- 
with siderails up. Mention to patient, "Siderails 
will be up when you first return from surgery. 
You may feel sleepy and be unsure of where edge 
of bed is due to medications." 
2. "FEET - PULL MD PUSH" 
a. Firmly and slowly pull feet and toes toward 
chin, then push feet and toes toward foot of 
bed. Relax. Both feet together, or- 
separately. (Figure 1, page 147.) 
b. Six times with each foot. 
3. "FEET - MAKE A CIRCLE" 
a. Position feet about ten inches apart. 
b. Firmly and slowly rotate feet on ankle joint 
so toes make a large circle. Relax. May do 
with both feet together or separately. 
(Figure 2, page 147.) 
c. Circle to right three times, then to left 
three times for a total of six complete ro¬ 
tations for each foot. 
4. "LEGS - PULL AND PUSH" 
a. Film shows flexion and extension of each leg 
by sliding foot along bed toward buttock to 
bend knee, then return leg to horizontal. Per- 
-80- 
form with each leg alternately,like riding a 
bicycle. Relax. (Figure 3, page 150.) 
b. Total of six times with each leg. 
c. An alternate method is shown in film with pa¬ 
tient lying on her side and performing the 
bicycle motion with upper leg only. (Figure 
5, page 151.) 
d. An optional method, not shown in film, is the 
same basic motions as in "a." above but moving 
both legs together at the same time. (Figure 
4, page 150.) 
5. "DEEP BREATHE" 
a. Head of bed raised as much as possible. 
b. Film shows deep breathing combined with arm 
exercises. First, exhale and place hands on 
mid-chest. Then take a slow, deep inhalation, 
consciously expanding abdomen and chest fully 
while extending both arms up and outward. 
Slowly exhale as completely as possible by 
compressing both abdominal and chest muscles 
while lowering hands to rest on mid-chest. 
Relax. (Figure 6, page 154.) 
-81 
c. The nurse may help emphasize correct technique 
by placing her hand on the patient's abdomen 
below the diaphragm. 
d. Total of six times. 
e. May omit raising and lowering of arms if de¬ 
sired unless these are ordered by surgeon. If 
this method is used, the patient would place 
his hands on his abdomen just above the 
umbilicus. (Figure 7, page 154.) 
f. If intermittent positive pressure breathing 
(IPPB) treatments are ordered, explain to pa¬ 
tient that there may be slight differences in 
their exact movements but the purpose is simi¬ 
lar. Remind patients that they are expected 
to do these exercises regularly between the 
IPPB treatments. 
g. If thoracic surgery, "The nurse will help you 
to support your incision at first when you 
deep breathe or cough." 
6. "DEEP COUGH" 
a. Head of bed raised as much as possible. 
b. Place hands in position to support incision, 
or on abdomen above umbilicus. Deep inhala- 
-82- 
tion momentary closure of glottis (". . . hold 
your breath a moment"), followed by firm con¬ 
traction of the abdominal and chest muscles to 
produce a sudden, forceful exhalation through 
the open mouth which pushes air and/or mucus 
out of the lungs. Relax, (Figure 8, page 157.) 
c. Two or three times. 
d. If inguinal herniorrhaphy, should always sup¬ 
port incision when coughing. Add use of upper 
thigh to support incision (explain, demon¬ 
strate, and have patient practice). One sur¬ 
geon requested omission of "Deep Cough" for 
his patients with herniorrhaphies. 
7. "SUPPORT INCISION" 
a. To be done only if indicated or helpful, 
especially when coughing or turning. 
b. Film shows use of arms alone, and arms with a 
pillow or bath blanket, for an upper right 
quadrant incision. (Figure 9 - A and B, page 
159.) Patients were shown where their incision 
would be and practice was specific for each 
patient. 
c. May also teach correct use of hands alone for 
-83- 
some patients, e.g., when a lower midline in¬ 
cision is anticipated. Place hands on either 
side of incision while exerting firm pressure 
downward and toward incision. (Figure 9 - C, 
page 159.) Use of upper thigh to support inci¬ 
sion was also taught to all patients expecting 
herniorrhaphies. (Figure 9 - D, page 159.) 
d. Patients were encouraged to use whatever method 
they found to be the most effective for them. 
e. If transurethral resection of the prostate or 
vaginal surgery, omit "Support Incision." 
Total film time would then be six and a half 
minutes. 
Explain to patient that he should do all acti¬ 
vities, but use care not to pull on tubing to 
urinary bladder when moving. 
f. If lumbar surgery, omit "Support Incision," 
"Turning Yourself," and the closing scene. 
Total film time would then be five minutes. 
8. "TURNING YOURSELF - 1. BACK TO SIDE. 2. SIDE 
TO BACK" 
a. Instruct patient not to do this alone at first. 
b. Back to side: If turning to the right, bend 
-84- 
left knee and place left foot flat on bed. 
Support incision with right arm and hand, push 
with left foot, grasp side rail with left hand 
and roll onto right side. (Figure 10,page 162.) 
c. Assume a comfortable position which avoids un¬ 
due pressure on arm next to bed and/or restric¬ 
tion of chest expansion. (Figure 11, page 163.) 
d. Side to back: Straighten upper leg if desired, 
support incision with arm next to bed, place 
fist or palm of upper arm firmly on the bed at 
a right angle, and push to roll onto back. 
(Figure 12, page 164.) 
e. Turn at least once every two hours. 
f. If lumbar surgery: See item 7.f. above. These 
patients were routinely instructed in log roll¬ 
ing by the nursing staff using demonstration 
techniques. 
9. Closing scene shows relaxed patient sitting in bed. 
III. Before Leaving Patient: 
A. Remind patient to "Go through the complete series 
every one or two hours." Might choose to do "Turning 
Yourself" on the hour between performing the others. 
B. Reassure patient that "Nurses will remind and help 
-85- 
you at first when you're still sleepy." 
C. When activities are to be continued throughout the 
night, explain that the nurses will be waking him 
up to do them. 
D. Leave patient as comfortable as possible. 
IV. The head nurse or team leader on duty at the time was 
notified which patients were taught by the investigator 
to avoid possible repetition of instruction. 
Data Collection Tool for Nursing Staff 
A one-page form was developed to obtain information from the 
nursing staff (See Appendix C, page 168). This was constructed using a 
combined checklist and rating scale format to permit focusing on data 
pertinent to the study, as well as to minimize the time required to 
respond. Another reason for this approach was to facilitate analysis 
of the information obtained. The investigator recognizes that there are 
several inherent weaknesses. The data collected by this tool is not 
completely descriptive and is subject to the vagaries of the respon¬ 
dent's interpretations. The responses obtained reflect only the per¬ 
ceptions of the nursing staff, not the validity of these perceptions. 
The main purpose was to obtain the nursing staff's evaluation 
of each patient's behavior postoperatively in terms of the activities 
being studied. This method of evaluation was chosen to eliminate the 
T-»86~ 
possibility of bias by the researcher in evaluating patients' perform¬ 
ance. These activities were identified by six names and a minimum for 
satisfactory performance was stated as follows: 
1. Exercise Feet (At least twice every two hours). 
2. Exercise Legs (At least twice every two hours). 
3. Deep Breathe (At least twice every two hours). 
4. Deep Cough (At least twice every two hours). 
5. Support Incision (When coughing or turning if indicated or 
helpful). 
6. Turn in Bed (At least once every two hours). 
The opinions of the nursing staff were sought for each of the 
three shifts within all twenty-four hour periods beginning on the day 
of surgery and continuously until the patient was discharged, or post¬ 
operative day seven, whichever occurred first. Three ratings were 
possible for each activity: 
1. Without reminding by nurse. 
2. Good when reminded by nurse. 
3. Poor when reminded by nurse. 
The wording "without reminding by the nurse" was used because in some 
instances family members would remind the patient. The focus for 
satisfactory performance was on the patient consistently performing the 
appropriate activities without the nurse always being present. The 
ratings were selected in terms of extremes to allow for differences in 
-87- 
interpretation of the meanings of "good" and "poor" when evaluating the 
quality of the patients’ performance. "At least twice (or "once" for 
turning) every two hours" was set as the minimum number of times that 
would be considered satisfactory. These lower limits were printed on 
the data collection forms to increase the likelihood of consistent 
interpretations by nursing staff on this point. 
Evaluation was to begin when the patient returned to the nurs¬ 
ing unit from the surgical recovery room. The ultimate goal, in most 
cases, would be for the patient to satisfactorily perform the appro¬ 
priate activities without reminding by the nurse. However, nursing 
staff and the investigator recognized that the last three activities 
would require nursing interaction with the patient at first. 
Specifically, patients were not expected to deep cough or turn 
themselves in bed without reminding until after they had done these 
activities with a nurse present. It may not be desirable for a patient 
to attempt deep coughing alone at first. The patient's turning in bed 
behavior is related to the surgical procedure itself and the patient’s 
state of alertness. Experimental group patients were instructed not to 
attempt to deep cough or turn themselves in bed the first time unless a 
nursing staff member was with them. Support of incision is not always 
indicated or helpful and so would not be expected of all patients. Some 
procedures, such as a thoracotomy, would usually require the assistance 
of the nurse to support the incision during the early postoperative 
-88- 
period. 
The lower portion of the data collection tool was designed to 
determine (1) the title of the person evaluating the patient's behavior, 
(2) whether or not any teaching concerned with the specified activities 
was done for patients in the control group, (3) if teaching was done, 
by whom, (4) when (preoperatively or postoperatively) teaching, if any, 
was done, (5) the amount of nursing time required for such teaching, 
and (6) the amount of time spent reminding patients in both groups re¬ 
garding these activities. The last two items were intended to elicit 
the approximate amounts of nursing time spent teaching and/or reminding 
patients to do the activities for both the experimental and control 
groups. Due to the incompleteness of the data obtained on these two 
items, it was not possible to analyze them as was originally planned. 
Nursing staff were invited to write any comments they wished on the 
back of the form. 
Collection of Data 
A meeting with the nursing service director, supervisors, and 
head nurses to share information and work out details with the investi¬ 
gator took place before data collection involving patients was begun. 
The data collection tool was placed in the charts of all patients 
included in both the control and experimental groups. This location 
was selected by the nursing staff for their convenience. Each form was 
-89- 
stamped with the patient's name to avoid inadvertent confusion, but the 
investigator removed this name from the form before taking this inforr- 
mation from the hospital. Data collection forms were collected by the 
investigator after the patient had been discharged or after postopera¬ 
tive day seven. A code number was assigned to each patient who became 
a part of the study and used for all data collection and analysis. This 
was done to provide anonymity for patients and facilitated later 
coordination of data elements. 
Discussions were held with part, but not all, of the nursing 
staff who would be using the data collection tool to report informa¬ 
tion and their evaluations. The intent was to clarify meanings of the 
terms being used and increase consistency of interpretations. 
Examination of each patient's chart at three points between 
admission and discharge provided additional data. Data collected the 
afternoon or evening prior to surgery and the evening of the day of 
surgery were used to establish the characteristics of the study popu¬ 
lation, including those factors related to the surgical treatment. The 
third review of the complete chart occurred after discharge or post¬ 
operative day seven. A fourth check was necessary for those patients 
who were discharged after postoperative day seven. These were for the 
purpose of extracting data concerning (1) agreement between observations 
recorded in the nursing notes and the evaluations reported on the data 
collection tool, (2) the postoperative day during which the patient was 
-90- 
first up and walking, (3) the number of days from surgery to discharge, 
(4) the number of analgesics given after leaving recovery room until 
discharge or postoperative day seven, (5) oral temperatures (when 
rectal temperatures were reported, they were converted to oral equiva¬ 
lents by subtracting one degree fahrenheit) as recorded on the nursing 
unit after surgery until discharge or postoperative day seven, (6) res¬ 
piratory rates as recorded on the nursing unit until discharge or post¬ 
operative day seven, and (7) evidence of postoperative complications 
experienced until discharge or postoperative day seven as identified by 
the attending surgeon. 
During the experimental preoperative teaching, the investigator 
wore her usual nursing uniform and cap. This was done to help create 
the illusion for patients of a regular staff nurse interacting with 
them. Patients were not told this was part of a research project and 
seemed to accept the investigator as part of the nursing staff. Nota¬ 
tions were made by the investigator immediately after leaving each 
patient’s room to provide the data necessary for reporting the amount 
of time involved when using this method of teaching. 
It should be noted that the term "postoperative day" as used in 
this study includes the day of surgery as one day, in addition to each 
of the other postoperative days which are conventionally designated as 
"P.0." or "postop" days, one through six. This was done to facilitate 
the subsequent analysis of data using statistical methods and to obtain 
-91- 
consistency in reporting information related to this study. 
Remainder of the Study 
Chapter IV contains the data and its analysis. The summary, 
conclusions, and recommendations are presented in Chapter V. 
CHAPTER IV 
DATA AND ANALYSIS 
Introduction 
This chapter contains summaries and interpretations of the 
data collected during the experimental portion of this study. Two 
groups of adult patients were formed from those who were admitted to 
the hospital during the four weeks between February 11 and March 11, 
1971 for common types of scheduled major surgery, and who met the 
criteria established for the study population. A total of sixty-eight 
(68) patients, thirty-four (34) in the control group and thirty-four 
(34) in the experimental group, represent the data producing sample. 
The control group was composed of patients admitted to the 
hospital during the first two weeks. Patients admitted during the last 
two weeks became the experimental group and received the experimental 
preoperative teaching which was conducted by the investigator. Both 
groups of patients received the same customary nursing care except for 
the addition of the planned teaching in the case of those who were in 
the experimental group. 
Data collection forms were placed in the charts for all sixty- 
eight patients to elicit information from the nursing staff regarding 
(1) the patient’s performance of the specified activities as evaluated 
by the nursing staff, and (2) the teaching component of customary 
nursing care with regard to the specified activities. 
-93- 
Additional data pertaining to the purposes and hypotheses 
previously set forth were collected in two ways: (1) the time involved 
in the experimental teaching was recorded by the investigator imme¬ 
diately after leaving each patient's room, and (2) other information 
needed to test the hypotheses was gleaned from the routine recordings 
made by physicians and nursing staff in each patient's chart. Data 
which related to the hypotheses formulated for this study was subjected 
to statistical analysis. 
The results from that portion of the data collection form 
designed to determine whether or not any teaching concerned with the 
specified activities was done for patients in the control group, as 
reported by the nursing staff, are shown in Table 7, page 94. Of the 
thirty-four patients in the control group, almost one-third received 
no teaching either pre- or postoperatively. Slightly more than one- 
third received some type of preoperative teaching, and slightly more 
than one-third were given some type of postoperative teaching. These 
findings are consistent with the statements made by Lindeman and Van 
Aernam indicating that there are variations in the teaching customarily 
provided by nurses for surgical patients.-*- The twenty-four patients 
Icarol A. Lindeman and Betty Van Aernam, "Nursing Intervention 
With the Presurgical Patient—The Effects of Structured and Unstruc¬ 
tured Preoperative Teaching," Nursing Research, XX (July-August, 1971), 
320. 
-94- 
for whom some type of teaching was reported were all taught by a 
registered nurse. One of these also received comprehensive teaching 
by a student professional nurse. 
Table 7. Frequency Distributions of Control Group Patients for 
Teaching of One of More of the Activities Being Studied as Reported by 
the Nursing Staff 
Number of 
Teaching Reported Patients 
No Teaching Reported Either Pre- or Postoperatively 10 
Some Type of Preoperative Teaching 12 
Some Type of Postoperative Teaching _12 
Total 34 
The investigator was unable to obtain information for a suf¬ 
ficiently large number of the patients in the study population to 
determine (1) the amount of nursing staff time spent in teaching 
which related to the specified activities with the control group, and 
(2) the amount of time spent reminding patients in either or both 
groups regarding these activities. Therefore, these points are 
omitted from this report. 
Time Involved During Experimental Teaching 
The third purpose of this study was to ascertain the amount of 
nursing time involved when using the film to help teach patients the 
-95- 
specified activities. Data collected by the investigator (based on 
her own notations) to determine the amount and distribution of time 
spent with patients during the experimental preoperative teaching is 
summarized in Table 8, page 96. The average amount of time involved 
with each patient (N=34) during this teaching was 12.05 minutes, with 
a range of from 5.50 to 18.00 minutes. 
The adjusted total time with the patient was determined by 
excluding time spent in interactions with other patients or persons 
(other than family or friends of the patient when the focus was on the 
patient and the activities) in the same room. Also excluded:'is addi¬ 
tional time which was devoted exclusively to listening to the anxieties 
of two patients. Film showing time average was 6.62 minutes, (range 
5 to 7 minutes). The average for narration and practice was 3.08 
minutes and ranged from .50 to 6 minutes. Examination of the infor¬ 
mation in Appendix F on pages 178-179 reveals that six patients spon¬ 
taneously practiced the activities while watching the film. This fact 
explains why the lower limit for narration and practice is .50 minutes. 
Because the investigator had not anticipated that patients might 
respond in this way, and to keep the experimental teaching as consis¬ 
tent as possible, no change was made in the previously planned narra¬ 
tion. In view of this observation, it is the opinion of this investi¬ 
gator that the nurse might appropriately suggest to patients that they 
practice while watching the film if desired. It is possible that if 
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-97- 
this were done the time required for teaching might be less than was 
found in this study. Time spent in other interactions with the 
patient and/or family or friends averaged 2.35 minutes and ranged 
from none to 6.25 minutes. This includes time which was not part of 
the planned narration and practice, but which was focused on the 
patient. 
Clearing the overbed table, and later replacing items moved, 
required "extra" time in many instances. However, it was not pos¬ 
sible to clearly distinguish this time from the introductory part of 
the planned teaching, and so it is included with the total for other 
interactions. 
The wide variation in the amount of time required for narration 
and practice was related, in most instances, to the quality of the 
patient’s performance during practice. The investigator evaluated how 
well the patient seemed to be performing each activity and offered 
encouragement and suggestions intended to stimulate the optimum level 
of performance. Deep breathing and deep coughing were the most diffi¬ 
cult for patients to perform satisfactorily during practice and 
required more practice than did any of the other activities. One 
possible implication of this observation is that these two activities 
might be even more difficult for some patients to perform postopera- 
tively when incisional discomfort and/or medications may interfere 
with their willingness or ability to deep breathe or cough. 
-98- 
Another factor related to the time spent in practice was the 
location of the patient during the teaching. The following summary 
is drawn from material in Appendix F, pages 178-179: 
Location and Position 
of Patients 
1. In Bed 
a. Flat or nearly flat 
b. Sitting or semi-sitting 
2. In a chair (sitting) 
Number of 
Patients 
25 
9 
16 
9 
Percent 
(N=34) 
73.5% 
26.5% 
47.0% 
26.5% 
Therefore, 73.5% of the patients in the experimental group practiced 
each activity which was appropriate for their anticipated surgery, 
whereas practice of leg exercises was modified and turning in bed 
practice was omitted during teaching time for 26.5%. The positions of 
the patients were reported above because one question related to using 
the motion picture was whether or not patients lying in bed would have 
difficulty seeing the picture on the screen clearly. It was the 
observation of this investigator that none of the patients who pre¬ 
ferred to remain flat or nearly flat during most of the film (they 
were rolled up to a sitting position for practice of deep breathing 
and deep coughing) gave any evidence of difficulty in viewing the 
pictures on the screen. 
-99- 
Patients1 Performance of Activities Postoperatively 
The fourth purpose of this study was to compare the postopera¬ 
tive performance of the specified activities, as evaluated by the 
nursing staff, of those patients who received only the customary nurs¬ 
ing care with those who received the experimental preoperative teaching 
using the motion picture. Inspection of Figure 13, page 100, reveals 
that in all cases the number of patients in the experimental group who 
first demonstrated satisfactory performance of activities during the 
day of surgery (after operation) was greater than the number of 
patients in the control group who achieved a similar level of perform¬ 
ance. Figure 14, page 100, shows the numbers of patients in the conr- 
trol and experimental groups who were demonstrating satisfactory 
performance of activities during the day after surgery. The experi¬ 
mental group continued to show more patients whose performance was 
satisfactory than did the control group. 
The numbers reported were obtained by examining the data 
collection form for each patient and then tabulating the first day 
(considering three nursing shifts, 11-7, 7-3, 3-11, as a day) when 
nursing staff indicated the patient demonstrated satisfactory perfor¬ 
mance with regard to each of the six specified activities. Although 
the data collection form (Appendix C on page 168) headings were 
designed to correspond with familiar hospital terminology, in analyzing 
the data, "P.0. 1" became postoperative day two, and the 11-7 shift 
-100- 
Patients 
36 
32 
28 
24 
20 
16 
12 
8 
4 
0 
II 12 
□ Control Group 
Experimental Group 
10 
Exercise I Exercise ' Deep 
Feet Legs Breathe 
(N= 
(N= 32) 
28) f t ■< 
17 a 
fM ::r 
; * . J . r ».• jk 
Cough* Incision* in Bed* 
Figure 13. Numbers of Patients in Control (N=34) and Experimental 
(N=34) Groups Who First Demonstrated Satisfactory Performance of 
Activities During the Day of Surgery (After Operation). 
*0mitted if not appropriate 
Patients 
36 
32 
28 
24 
20 
16 
12 
8 
4 
0 
Figure 14. Numbers of Patients in Control (N=34) and Experimental 
(N=34) Groups Who Were Demonstrating Satisfactory Performance of 
Activities During the Day After Surgery. 
*0mitted if not appropriate. 
17 20 
□ Control Group 
Experimental Group 
ExerciseI Exercise 
Feet Legs 
15 
Deep • Deep 
Breathe Cough* 
(N= 
(N= 19) 
Support 
Incision* 
Turn 
in Bed* 
-101- 
under that heading was considered with the subsequent twenty-four hour 
period. 
A summary distribution of the titles of the nursing staff who 
made the reported evaluation, (as shown on the data collection form,) 
on each shift, for each patient, was as follows: 
Title 
Registered Nurse (R.N.) or Student 
Professional Nurse (S.N.) Only 
Licensed Practical Nurse (L.P.N.) Only 
Ward Aide (W.A.) or Orderly(ORD.) Only 
R.N. or S.N., and L.P.N. Only 
R.N. or S.N., and W.A. or ORD Only 
L.P.N., and W.A. or ORD. Only 
All three categories (i.e., R.N. or 
S.N.; L.P.N.; W.A. or ORD) 
Totals 
Control Experimental 
Group Group 
22 
0 
3 
5 
2 
0 
14 
0 
0 
14 
2 
0 
_2 _4 
34 34 
Six null hypotheses were formulated in relation to the fourth 
purpose of this study. Chi-square tests were used to determine the 
significance of the differences between the control and experimental 
groups according to the six time categories indicating the day during 
which each patient first satisfactorily performed each of the six 
different activities specified. 
-102- 
A .20 level of significance, for a one-tailed test,was accepted 
as significant. The .20 level of significance increases the probability 
of a Type I error. Use of a lower level of significance would reduce 
the probability of a Type I error, but would increase the possibility 
of a Type II error. A Type II error is undesirable in view of the 
2 
exploratory nature of this investigation. The investigator is also 
aware that findings of statistical significance or nonsignificance 
3 
are not necessarily reliable indicators of practical significance. 
Further investigations would be required before any generally appli¬ 
cable conclusions could be established. 
Six time categories, including "never," were used in computing 
the chi square because it was found upon inspecting the raw data that 
if a patient had not demonstrated "satisfactory performance" on or 
before postoperative day five, he never did so during the data collec¬ 
tion period. Therefore "never" was established to mean before dis¬ 
charge or the seventh day after surgery (counting the day of surgery as 
one), whichever occurred first. 
^John T. Roscoe, Fundamental Research Statistics for the 
Behavioral Sciences (New York: Holt, Rinehart and Winston, Inc., 
1969), pp. 154-155. 
3 
Faye G. Abdellah and Eugene Levine, Better Patient Care 
Through Nursing Research (London: The Macmillan Company, Collier- 
Macmillan Limited, 1965), pp. 372-375. 
-103- 
Tables 9, 10, and 11, (pages 104, 105, 106) present the compar¬ 
isons among the control and experimental groups of patients for the six 
time categories indicating the postoperative day during which each 
patient first satisfactorily performed feet exercises, leg exercises, 
or deep breathing respectively. The chi square table value for five 
4 
degrees of freedom at the .20 level of significance is 7.289. Since 
2 
the computed chi squares (feet exercises, X =10.29; leg exercises, 
2 2 X =7.47; deep breathing, X - 8.14) were greater than the table chi 
square value, the null hypotheses that there is no significant dif¬ 
ference between the control and experimental groups in terms of the 
postoperative day during which the patient first demonstrates that he 
is satisfactorily performing (1) feet exercises, (2) leg exercises, 
and (3) deep breathing were rejected. Thus, it may be that in terms 
of these three behaviors, the experimental preoperative teaching was 
influential in helping patients to perform more effectively and sooner 
than did those patients who did not receive the experimental preopera¬ 
tive teaching. 
^Allen L. Edwards. Statistical Methods (2nd. ed.; New York: 
Holt, Rinehart and Winston, Inc., 1967), p. 424. 
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Tables 12, 13, and 14 (pages 108, 109, 110) present the same 
type of information for the deep coughing, support incision, and turn 
in bed activities. Since the computed chi squares (deep coughing, 
o o 2 
X = 3.53; support incision, Xz = 3.43; turn in bed, X =3.77) were 
less than the table chi square, the null hypotheses that there is no 
significant difference between the control and experimental groups in 
terms of the postoperative day during which the patient first demon¬ 
strates that he is satisfactorily performing (4) the deep cough 
activity, (5) support of incision when coughing or turning, if this is 
indicated or helpful, and (6) the turning self in bed activity were 
accepted. 
Deep coughing is less likely to be performed correctly by 
the patient unless he receives postoperative follow-up instruction 
and encouragement, whether or not he was taught preoperatively. 
Evaluation of this variable was beyond the scope of this study. Also, 
experimental groups patients were instructed not to do this alone at 
i 
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told this. 
Table 13 on page 109, for support of incision, contains a total 
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nineteen (19) in the experimental group because this activity was not 
indicated for thirty-six patients in the study population. Table 14 on 
page 110, turning in bed, does not include six patients in the control 
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-111- 
group and two patients in the experimental group who had lumbar sur¬ 
gery. Patients in the experimental group were instructed not to turn 
themselves the first time alone, and this may have been an inhibiting 
factor. In the clinical situation it is not uncommon for patients to 
turn themselves in bed very soon after surgery. 
Patients' Postoperative Physiologic Status 
The fifth purpose of this study was to compare selected charac¬ 
teristics of both groups which might represent indicators of the 
patients' postoperative physiologic status. Six null hypotheses were 
developed in relation to this purpose. 
Data reported in Table 15 on page 112,showing the postoperative 
day during which each patient was first up and walking, was based on 
two sources: (1) the surgeon's written order for the patient to be up, 
and (2) the nurses' notes indicating that the patient actually walked 
at least a few steps with or without help. Seven time categories 
appear because three patients in the study population were first up and 
walking on postoperative day seven. All three of these patients had 
undergone lumbar surgery. Forty-seven of the total sixty-eight 
patients were up and walking during either the day of surgery or post¬ 
operative day two. 
The chi square table value for 6 degrees of freedom at the 
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-113- 
.02 level of significance is 8.558. Since the computed chi square 
(X^ = 6.04) was less than the table chi square, the null hypothesis 
that there is no significant difference between the control and ex¬ 
perimental groups in terms of the postoperative day during which the 
patient is first up and walking was accepted. 
No data were collected in this study to determine the quality 
or extent of the patient's efforts at walking, nor was it possible to 
determine how soon the patient was able to walk safely without assis¬ 
tance. It might be speculated that those patients who effectively 
performed the specified activities would be more capable when ambulat¬ 
ing than those who did not. Information about when the patient was 
first "up and walking" would be more meaningful as an indicator if it 
were obtained in combination with related variables. In addition to 
each patient's actual physical and emotional status, the individual 
philosophy of the attending surgeon would be an influential factor. 
Data for, and results of, the t tests used to determine the 
significance of the differences in the means and standard deviations 
between the control and experimental groups in terms of four other 
indices examined are shown in Tables 16, 17, 18, and 19 (pages 116, 
119, 121). The t value for these data, based on 66 degrees of freedom 
’’Edwards, p. 424. 
-114- 
at the .20 level of significance, is 0.842. 
Table 16 on page 116 presents the means and standard deviations 
of the control and experimental groups for the number of days from sur¬ 
gery to discharge. When tabulating this data, the day of surgery was 
counted as one day, then each subsequent day (including the day that 
the patient actually left the hospital) was added to arrive at a total 
for each patient. No corrections were made for the variations in the 
specific time of the surgical procedure or the exact time of day when 
the patient left the hospital. The computed t value was 0.86 and so 
the null hypothesis that there is no significant difference between 
the control and experimental groups in terms of the number of days from 
surgery to discharge was rejected. Inspection of the table reveals 
that the difference, although statistically significant at the .20 
level, is not great. However, this finding that patients who received 
the experimental preoperative teaching were able to leave the hospital 
earlier than those who did not receive such instruction, is in agree¬ 
ment with the report of Lindeman and Van Aernam. They found a statis¬ 
tically significant difference beyond the .02 level with 237 degrees 
of freedom when evaluating similar types of data.^ 
The means and standard deviations of control and experimental 
Edwards, p. 425. 
^Lindeman and Van Aernam, pp. 328 and 330. 
-115- 
groups of patients for the number of analgesics given after leaving 
recovery room until discharge or postoperative day seven are reported 
in Table 17 on page 116. The t value for these is 0.95, which is 
greater than the table value (t = 0.842); therefore the null hypothesis 
that there is no significant difference between the control and experi¬ 
mental groups in terms of the number of analgesics given after leaving 
recovery room until discharge or postoperative day seven was rejected. 
It may be that the experimental preoperative teaching resulted in 
postoperative behaviors of patients which, at least to some extent, 
decreased their discomfort and need for analgesics. Numerous un¬ 
controlled variables enter into the circumstances related to the admin¬ 
istration of analgesics and so this is only a speculative finding. 
In this study the number of analgesics received by each patient was 
determined by counting the number of times any form of analgesic medi¬ 
cation was actually received by each patient. No adjustments were 
made for the specific types of the analgesics or the dosages in estab¬ 
lishing the total number of analgesics given to each patient. 
The number of analgesics received by patients who were given 
some structured form of preoperative teaching, as compared to those 
patients who were not thus instructed has been examined by other 
researchers. Their criteria for comparison were different from the 
one chosen for this study. Healy used the day when oral narcotics were 
begun, and she reports a numerical difference in favor of her 
-116- 
Table 16. Means and Standard Deviations of Control and Experimental 
Groups for the Number of Days from Surgery to Discharge 
N=34 
Control 
Group 
N=34 
Experimental 
Group 
t-Test 
Number of Days 
From Surgery 
to Discharge 
Mean 7.35 6.76 
.86* 
S.D. 3.24 2.30 
df = 66 
^Significant beyond the .20 level. 
Table 17. Means and Standard Deviations of Control and Experimental 
Groups for the Number of Analgesics Given After Leaving Recovery Room 
Until Discharge or Postoperative Day Seven 
N=34 
Control 
Group 
N=34 
Experimental 
Group 
t-Test 
Number of Analgesics 
Given After Leaving 
Recovery Room Until 
Discharge 
Mean 14.71 11.59 
.95* 
S.D. 14.79 11.99 
df = 66 
’"'Significant beyond the .20 level. 
-117- 
Q 
experimental group. Egbert and others carefully evaluated postopera¬ 
tive treatment with narcotics (from surgery through the fifth day after 
surgery) in their experimental study and found that "... postopera¬ 
tive narcotic requirements [were reduced] by half" for those patients 
Q 
who had received their "Special-care" instructions. However, they 
found no statistically significant difference between their groups for 
narcotic requirements on the day of surgery. Lindeman and Van Aernam 
found no statistically significant difference between their control 
and experimental groups in terms of the number of analgesics given ". . 
. during the first 72 postoperative hours.It might be speculated 
that patients experience comparable discomfort in the early postopera¬ 
tive period, and the benefits of preoperative teaching with 
postoperative performance of stir-up activities becomes apparent at 
some subsequent point in time. 
Two commonly recorded measurements (i.e., body temperature and 
respiratory rates) of patients’ physiologic status were considered in 
^Kathryn M. Healy, "Does Preoperative Instruction Make a Dif¬ 
ference?" American Journal of Nursing. LXVIII (January, 1968), 67 
g 
Lawrence D. Egbert et al., "Reduction of Postoperative Pain 
by Encouragement and Instruction of Patients," New England Journal of 
Medicine, CCLXX (April 16, 1964), 825-827. 
■^Lindeman and Van Aernam, p. 330. 
-118- 
this study. Although there are expected alterations in normal 
physiology related to the experience of surgical treatment, it is 
possible that certain deviations from a "normal" baseline would serve 
as indices to possible postoperative complications. To facilitate 
summarization and analysis of the raw data, some arbitrary decisions 
were made. This was also done to reduce the possibility of wide varia¬ 
tions, due to normal fluctuations and/or differences in techniques, 
among the reported temperature readings and respiratory rates. 
Temperature readings for each patient were categorized into three 
groups: (1) total times below 100.0° F., (2) total times 100.0° F. to 
100.4° F., and (3) total times 100.6° F. or above. Table 18 on page 
119 shows the means and standard deviations of control and experimental 
groups as recorded on the nursing unit after surgery until discharge 
or postoperative day seven, as well as the total times temperature 
readings were to be taken for the patients. The t test value for total 
times to be taken was 0.39, which is not statistically significant, and 
the groups may be considered comparable on this item. No significant 
difference was found for (1) total times below 100.0° F., (t = 0.10), 
or (2) total times 100.6° F., (t - 0.34). A significant difference was 
found for the total times the temperature reading was 100.0° F. to 
100.4° F., (t = 1.11). These categories had been established in view 
of such opinions as, "with diligent attention to preventive and 
therapeutic measures to maintain optimum pulmonary ventilation, most 
-119- 
Table 18. Means and Standard Deviations of Control and Experimental 
Groups for Oral Temperatures as Recorded on the Nursing Unit After 
Surgery Until Discharge or Postoperative Day Seven. 
Postoperative Oral Temperatures 
N=34 
Control 
Group 
N=34 
Experimental 
Group 
t-Test 
Total Times 
To Be Taken 
Mean 10.44 10.21 
0.39 
S.D. 2.30 2.72 
Total Times 
Below 100.0° F. 
Mean 8.82 8.76 
0.10 
S.D. 2.43 2.46 
Total Times 
100.0° F. to 
100.4° F. 
Mean 1.00 .71 
1.11* 
S.D. 1.18 1.00 
Total Times 
100.6° F. 
or Above 
Mean .62 .74 
0.34 
S.D. 1.48 1.38 
df = 66 
Significant beyond the .20 level. 
-120- 
patients can undergo prolonged and complicated surgical procedures with 
Xi 
postoperative temperatures never exceeding 100.4° F. (38° C.)." In 
view of the inconclusive findings, the null hypothesis that there is 
no significant difference between the control and experimental groups 
in terms of oral temperatures as recorded on the nursing unit after 
surgery until discharge or postoperative day seven was accepted. 
Table 19 on page 121 shows the means and standard deviations of 
both groups for respiratory rates as recorded on the nursing unit after 
surgery until discharge or postoperative day seven. The computed t 
test for the total times the respiratory rate was to be recorded was 
0.39, which indicates that there was no significant difference between 
the populations of these groups on this item. 
Two categories were established for comparisons of the respi¬ 
ratory rates: (1) total times twenty per minute or below, and (2) total 
times above twenty per minute. Since the computed t value (t = 0.56 
and 0.37) were less than the table value (t = 0.842) the null hypothesis 
that there is no significant difference between the control and experi¬ 
mental groups in terms of the respiratory rates as recorded on the 
nursing unit after surgery until discharge or postoperative day seven 
^Committee on Pre and Postoperative Care, American College of 
Surgeons, Manual of Preoperative and Postoperative Care (Philadelphia: 
W. B. Saunders Co., 1967), p. 156. 
-121- 
Table 19. Means and Standard Deviations of Control and Experimental 
Groups for Respiratory Rates as Recorded on the Nursing Unit After 
Surgery Until Discharge or Postoperative Day Seven 
Postoperative Respiratory Rates 
N=34 
Control 
Group 
N=34 
, Experimental 
Group 
t-Test 
Total Times 
To Be Taken 
Mean 10.44 10.21 
0.39 
S.D. 2.30 2.72 
Total Times 20 
or Below 
Mean 9.50 9.15 
0.56 
S.D. 2.92 2.19 
Total Times 
Above 20 
Mean 1.18 1.03 
0.37 
S.D. 1.68 1.57 
df = 66 
-122- 
was accepted. This finding is consistent with the finding that only 
one patient in each group presented postoperative clinical evidence 
of a respiratory complication. 
The last hypothesis in this study, i.e., there is no signifi¬ 
cant difference in terms of postoperative complications experienced 
until discharge or postoperative day seven as identified by the 
attending surgeon was accepted on the basis of the following data 
(no statistical analysis was done): 
Postoperative Complications 
Respiratory 
Circulatory 
Wound Disruption 
Wound Infection 
Other 
Control 
Group 
(N=34) 
1 
0 
0 
0 
0 
Experimental 
Group 
(N=34) 
1 
0 
0 
0 
0 
This data was obtained by examining the "Doctors Progress Notes" and 
"Discharge Summary" sections of each patient's chart. 
Comments from Patients, Surgeons and Nursing Staff 
This study did not include a formal plan for obtaining comments 
from patients, but the investigator did record some examples of spon¬ 
taneous remarks made by patients related to the experimental preopera- 
-123- 
tive teaching. When first approached, two patients requested that 
the nurse (investigator) return after visiting hours because of the 
brief time available for them to talk with their spouses. This was 
done. One patient initially appeared almost hostile, but her attitude 
and facial expression changed markedly when she began watching the 
film. She remarked, "I’ll be groggy, but I’ll remember some of them." 
It was interesting to note that, according to the reports on the data 
collection form, she was satisfactorily performing all of the activi¬ 
ties during the day after surgery. 
Three patients related the activities to other experiences 
they were familiar with. One man said, "Some of those are like what 
I did in army training." Two ladies reported they exercised regularly 
at home. Another lady seemed enthusiastic and related her feelings 
of well-being when she got up the evening of surgery following a recent 
cholecystectomy as compared to an appendectomy earlier when she spent 
nine days in bed. Persons who had previous surgery offered various 
ideas. Only one patient had been taught similar activities in relation 
to previous surgery. That lady indicated she agreed they were impor¬ 
tant and although she recalled how to do them, said "I'm glad you re¬ 
minded me." The roommate of. one patient described the emphasis her 
physician had placed on such activities. A man explained no one had 
ever taught him before, but "I figured out for myself how much that 
-124' 
kind of thing helps when I had surgery four years ago." "I’ll bet 
that would help to keep your legs from aching," or "Moving like that 
should help relieve gas pains, too" were volunteered by different 
patients and/or family members. The most typical remarks were "I 
wish I had known about this when I had my other surgery," and "It's 
nice to know what you can do." This last remark was also typical of 
those patients who had not had previous surgery. 
Some of the patients made written notes for themselves, and 
family members of two others carefully recorded details about the 
activities. Concern that they might not remember was expressed by 
two different patients who queried, "Someone will remind me, won't 
they?" These events led the investigator to believe that some type 
of printed and/or illustrated material should probably be provided 
for every patient. This idea has been recommended in two published 
articles.^ 
This experimental group included two gentlemen (aged 67 and 
82 years) with severe uncorrected hearing loss. Both watched the film 
intently and one very carefully practiced each activity as it was 
being shown. When the film was stopped after each scene, the 
12 Daniel J. Leithauser, "Early Ambulation," The American 
Journal of Nursing. L (April, 1950), 203, 206. 
13 Elizabeth J. Mezzanotte, "Group Instruction in Preparation 
for Surgery." American Journal of Nursing. LXX (January, 1970), 90.. 
-125- 
investigator used finger signals and lip movements to indicate the 
number of times and how frequently to do each activity. This patient 
replied verbally, which provided a way of checking that he understood. 
The wife of the other man was present during the teaching. She wrote 
down the information about number of times and frequency which the 
patient then read aloud and demonstrated the movements to show that he 
understood. 
A spontaneous postoperative opinion was obtained when one 
patient, four days after surgery, stopped the investigator in the 
hallway and described her feelings. She concluded with "I think it 
helped me feel better to do those exercises. That's sure a good idea 
to tell people about them before they have surgery. 
Surgeons, in general, seemed pleased to have their patients 
receive the preoperative teaching. One explained that he believed 
these activities were especially important for "older" patients and 
cited transurethral resection of the prostate as one procedure for 
which patients ought to be encouraged to deep breathe, exercise their 
feet and legs, and so on. Orthopedic surgeons seemed to feel that, 
with suitable modifications for the individual patients, this stir- 
up instruction would be beneficial. An obstetrician expressed 
interest in seeing this type of teaching provided to his patients who 
had cesarean sections. Although a few of the general surgeons were 
-126- 
quite enthusiastic, the more typical comment was "That seems like a 
good idea." 
Comments were invited from the nursing staff on the data col¬ 
lection form. The most common notation, for both the control and 
experimental groups, when the patient’s response was poor, was 
"Drowsy." One patient "just doesn’t seem to care"; his behavior was 
poor on all the activities. The necessity of follow-up explanations 
was illustrated for one patient in the experimental group with "Patient 
thought she would tear stitches if she turned, was doing other exer¬ 
cises well without reminding. Turned okay after we explained and 
reassured her." The fact that family members were reminding the 
patient was also reported, as was "patient cooperative." 
Various nursing staff members, near the end of this study, 
volunteered their opinions about the effect of the teaching. Typical 
remarks were "That really seems to help. The patients know what to 
do and go right ahead." "I wish all the patients could see that film, 
it sure makes a difference after surgery. I can tell which ones saw 
it." 
Nursing staff who saw the film also offered suggestions, such 
as (1) another film could be made about techniques for getting out of 
bed and walking, (2) a film showing a male patient might help increase 
-127- 
some patients’ sense of identification, (3) teaching for small groups 
of patients might conserve time, and (4) a series of films with 
activities specific for the different types of surgery could be 
useful. 
CHAPTER V 
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 
Summary 
The problems considered in this study were (1) could a color, 
silent film providing visual examples of activities to be performed by 
surgical patients be produced and used by a nurse; (2) what would be 
the related approximate expenditures of money and time; (3) will 
planned patient-teaching by a nurse the evening before surgery, of 
selected (stir-up) activities utilizing a motion picture, result in 
improved patient performance of these activities postoperatively as 
compared to the performance of those patients who receive no structured 
teaching of these activities; (4) is there any difference between 
patients who receive such planned instruction and those who do not in 
terms of, first day up and walking, length of post-surgical hospital 
stay, number of analgesics received, postoperative temperature read¬ 
ing, postoperative respiratory rates, and evidence of postoperative 
complications? 
This investigation had five purposes: (1) develop a color, 
silent motion picture showing six selected activities which the adult 
surgical patient may be expected to perform postoperatively and a 
written nurse’s guide containing suggestions for using the film; (2) 
use this motion picture and guide in giving preoperative instructions 
-129- 
to adult patients scheduled for common types of major surgical treat¬ 
ment other than surgery of the head, neck, extremities, tubal ligation, 
or cesarean section; (3) ascertain the amount of nursing time involved 
when using the film to help teach patients these activities; (4) 
compare the postoperative performance of these activities, as 
evaluated by the nursing staff, of those patients who received only 
the customary nursing care with those who received the experimental 
preoperative teaching using the motion picture; and (5) compare 
selected characteristics of both groups which might represent indica¬ 
tors of the patient's postoperative physiologic status. 
The aims of this study were both methodological and explora¬ 
tory. A review of the literature and consultation with experts in the 
fields of surgery, nursing, and educational media production served 
as the foundation for preparing the motion picture, nurse’s guide, and 
the experimental preoperative patient-teaching outline. The content 
of the film and the experimental patient-teaching plan was restricted 
to six of the stir-up activities. These represent only a segment of 
the numerous elements involved in preoperative teaching for surgical 
patients. 
The experimental portion of this study was conducted in a 
clinical setting with patients and nursing staff on a general hospi¬ 
tal’s surgical nursing units. The study population consisted of 
sixty-eight (68) patients who met the following criteria: 
-130- 
(1) scheduled for a common type of major surgery, as defined for this 
study, (2) in the hospital the evening before surgery, (3) eighteen 
years of age or older, (4) sufficiently alert to be oriented to time 
and place, (5) capable of understanding and following simple directions 
in English, (6) functional vision either with or without corrective 
lenses, and (7) permission from the patient’s surgeon for the patient 
to be included in the study. Thirty-four (34) patients admitted to 
the hospital during the two weeks from February 11 through February 25, 
1971 formed the control group and received customary nursing care with 
no structured teaching. The experimental group was composed of thirty- 
four (34) patients admitted during the two weeks from February 26 
through March 11, 1971 who received customary nursing care, and also 
the planned experimental teaching carried out by the investigator. 
Patients’ ages ranged from twenty to eighty-three years. There were 
forty-three men and twenty-five women in the total data-producing 
s amp le. 
Data reported in Chapter IV was collected in three ways. A 
data collection tool was designed by the investigator to elicit (1) an 
evaluation by the nursing staff of each patient's performance of the 
selected activities, and (2) the titles of the persons reporting, the 
time spent by nursing staff in teaching or reminding patients about 
these activities and comments from nursing staff. This data collection 
form was placed in the chart of each patient in both the control and 
-131- 
experiment al groups. Notations regarding the time spent in the ex¬ 
perimental preoperative teaching for each patient in the experimental 
group were prepared by the investigator. Hospital charts of all 
patients in the study were examined by the investigator to collect data 
on length of hospital stay after surgery, number of analgesics given, 
first day up and walking, body temperature readings, respiratory rates, 
and reported evidence of complications. Relevant data was collected 
for each patient until discharge or postoperative day seven. Twelve 
null hypotheses had been developed with respect to the fourth and fifth 
purposes of this study, and data pertaining to these was subjected to 
statistical analysis. 
It would have been desirable to include larger numbers of 
patients, and to use a design involving three groups (i.e., customary 
nursing care only, structured preoperative teaching with a film, struc¬ 
tured preoperative teaching without a film) to test more accurately the 
influence of the motion picture on patients' learning as evidenced by 
their postoperative behavior. Comprehensive planning by both nurses 
and surgeons, followed by an in-service program for all nursing staff, 
would create a more uniform basis for evaluation of patients' behavior. 
This should also generate more consistent postoperative nursing care 
and thus reduce the influence of another important variable. 
-132- 
Concluslons 
The findings in this investigation indicate that some tentative 
conclusions may be stated. It was found that a super-8mm motion pic¬ 
ture, suitable for patient-teaching, can be produced with a moderate 
expenditure of time and money, if the required equipment and technical 
knowledge are available. It is the opinion of the investigator that 
such a film, with a guide for its use, may easily be used by a nurse 
while teaching preoperative patients about their postoperative activi¬ 
ties. Further study, involving other nurses, would be necessary to 
substantiate this opinion. 
The amount of nursing time involved when using the film to help 
teach patients about their postoperative activities averaged 12.05 
minutes per patient, with a range of from 5.50 to 18.00 minutes. 
Insufficient data was obtained to provide any statement as to how this 
amount of time compares to the nursing time required for preoperative 
patient-teaching without using the film. Patients were taught on an 
individual basis, and it is possible that teaching small groups of 
patients in combination with individual follow-up would be more effi¬ 
cient, and perhaps more effective. 
Numerical counts revealed that more of the patients in the 
experimental group satisfactorily performed the six activities (i.e., 
feet exercises, leg exercises, deep breathing, deep coughing, support 
incision, and turn in bed) than did those patients in the control 
-133- 
group. Null hypotheses related to this finding were tested at the 
.20 level of confidence which merits the drawing of only tentative 
conclusions. 
A significant difference was found between the control and 
experimental groups of patients in terms of the postoperative day 
during which each patient first satisfactorily performed feet exer¬ 
cises, leg exercises, and deep breathing. It may be that the 
experimental preoperative teaching using the film was influential in 
producing this finding. 
No significant difference was found between the control and 
experimental groups of patients in terms of the postoperative day dur¬ 
ing which each patient first satisfactorily performed deep coughing, 
support of incision, and turning in bed. This finding may be related 
to the observation of this investigator (and supported by other 
writers) that deep coughing is frequently difficult for postsurgical 
patients and requires further instruction and encouragement post- 
operatively. The number of patients for whom support of incision was 
appropriate represents slightly less than 50 percent of the total study 
population. Turning in bed may be an activity that most patients will 
perform whether or not they receive instructions about it. The con¬ 
clusion drawn from these findings is that there does seem to be 
sufficient evidence to warrant further study of the effects on surgical 
patients’ behavior from structured preoperative teaching using a film 
-134- 
about postoperative activities. 
Of the six null hypotheses tested with regard to selected 
characteristics of both groups which might represent indicators of 
the patients' postoperative physiologic status, a significant differ¬ 
ence was found for two, at the .20 level of significance. Patients 
in the experimental group were discharged from the hospital slightly 
sooner after surgery than were those in the control group, the 
difference in average number of days was 0.59. This margin is so 
narrow that no conclusion may be drawn. Experimental group patients 
received fewer numbers of analgesics than did patients in the control 
group; the difference in average number of analgesics was 3.12. Thus 
it might be speculated that the preoperative teaching resulted in a 
decrease in the patients' postoperative discomfort and attendant need 
for analgesics. 
The null hypotheses that there is no significant difference 
between the control and experimental groups in terms of (1) the day 
during which each patient was first up and walking, (2) the oral 
temperatures or (3) respiratory rates as recorded on the nursing unit 
after surgery until discharge or postoperative day seven, and (4) 
postoperative complications experienced until discharge or postopera¬ 
tive day seven as identified by the attending surgeon were all 
accepted. The conclusion emerging from these findings is that there is 
no apparent difference between patients who received the experimental 
-135- 
preoperative teaching and those who did not receive such teaching on 
the basis of these variables. 
Patients verbalized their appreciation at receiving the 
experimental preoperative teaching. Not all were certain of their 
ability to remember. In view of this observation, and reports by 
other writers, it is suggested that some form of brief written and/or 
pictorial reminder should be provided each patient. Observations of 
patients’ behaviors, made by the investigator while using the film 
in teaching patients, indicate that the film appears to attract and 
hold patients’ interest. Some members of the nursing staff stated 
that, in their opinion, patients who had been given the experimental 
preoperative teaching in general performed the activities more effec¬ 
tively, and with less reminding by staff, than did patients in the 
control group. 
Recommendations 
1. If a similar study were to be done, it would probably be 
advantageous to develop specific details for the experimental pre¬ 
operative teaching in view of the hospital, surgeons, and nurses where 
the study would be conducted. All nursing staff involved should be 
oriented to the nature of the teaching plan and the manner in which 
patients would be expected to perform the activities postoperatively. 
2. A more uniform evaluation might be obtained if the study 
-136- 
were limited to patients scheduled for one category of surgical inter¬ 
vention. In any case, a longer time period and larger numbers of 
patients would be desirable. 
3. A broad survey to determine more clearly what the existing 
practices for preoperative instruction are. This might include what 
techniques of teaching are being used and the relative expenditures 
of nursing time. 
4. The contribution to learning made by a motion picture should 
be studied more definitively. This might be done by using three groups 
of patients. One group would receive customary nursing care with no 
structured teaching, one group structured verbal teaching with demon¬ 
strations, and one group structured verbal teaching with a film. All 
three groups might be provided with brief printed instruction sheets. 
5. A study might be done which incorporated the idea of a 
variety of brief films, each of which was specific for a given type of 
surgical procedure* 
6. Several nurses, other than the investigator, should parti¬ 
cipate in the experimental preoperative teaching. The film, projector, 
and screen should be mounted on a wheeled cart for convenience. 
7. The effectiveness of using a film with small groups of pre- 
surgical patients, including individual follow-up, should be explored. 
APPENDICES 
-138- 
APPENDIX A 
NURSE’S GUIDE FOR USING THE MOTION PICTURE 
"YOU AFTER SURGERY: IMPORTANT ACTIVITIES" 
by 
Dolores A. Burger 
Montana State University 
Bozeman, Montana 
Pages 138-165 inclusive 
Copyright 
(c) Dolores A. Burger 1971 
The author wishes to express her appreciation 
to Grace France who prepared the drawings. 
-139- 
CONTENTS 
Section . Page 
Introduction  140 
Questions to Consider  141 
Suggestions for Use  142 
Basic Activities  146 
Exercise Feet   146 
Exercise Legs   148 
Deep Breathing  152 
Deep Coughing  155 
Support of Incision by the Patient  158 
Turning of Entire Body by the Patient Himself .... 160 
140- 
NURSE'S GUIDE FOR USING THE MOTION PICTURE 
"YOU AFTER SURGERY: IMPORTANT ACTIVITIES" 
A super-8mm, silent, color film. 
Approximate Total running time: 7 minutes 
Approximate Total running time when omitting "Support Incision" scene: 
6-1/2 minutes 
Approximate Total running time when omitting "Support Incision," 
"Turning Yourself," and Closing Scenes: 5 minutes 
Introduction 
This film is designed to be used by a nurse while teaching 
preoperative patients about some of their postoperative activities. 
Potential advantages of using the film include: 
1. The motion pictures communicate readily with most patients. 
2. Patients learn more easily when they can actually see the 
movements they are learning. 
3. Nursing time is conserved because less repetition of 
instruction is needed. 
The central objectives of the stir-up activities are (1) to 
combat the physical depression and trauma associated with surgical 
treatment, (2) assist in prompt restoration of normal functioning of 
all the body systems, and (3) prevent the development of potential 
complications, (4) reduce the intensity and duration of the discom¬ 
forts experienced by the patient, and (5) encourage prompt return to 
the maximum state of recovery possible for each individual. 
-141- 
The film is silent allowing the nurse to provide the necessary 
explanations in terms that will be understandable to different 
patients. Specific instructions, such as how often and how many times 
each activity should be performed, may readily be varied to fit partic¬ 
ular situations. 
A plan which provides for individual differences within the 
framework of the hospital where the film will be used is essential. 
Decisions and recommendations from staff surgeons and nurses are 
needed to generate information that is as consistent as possible. 
Questions to Consider 
Questions that need to be answered would include: 
1. Which activities should be taught to patients within 
designated general categories of surgical procedures? 
2. What are the recommended concepts to use when giving the 
patient reasons why he should perform these activities? 
3^ Which manner of executing each activity is preferred, 
and is more than one way acceptable? 
4. When should the patient begin performing each activity 
postoperatively: 
a. with the help of a nurse? 
b. on his own initiative? 
5. How often should the patient perform each activity (e.g.. 
- 142- 
eve ry hour, every two hours)? 
6. How many times should each activity be done (e.g., two, 
four, or'six times)? 
7. Are activities to be performed regularly throughout each 
twenty-four hours, or except when asleep at night? 
8. For how long postoperatively should the patient do each 
of the activities (e.g., until the fifth or sixth day after surgery; 
until discharged from the hospital; until up and walking several hours 
each day)? 
9. Are there any special instructions which are to be taught 
for specific surgeons and/or specific kinds of surgery? 
Suggestions for Use 
The activities shown in the film are arranged so that some may 
be easily omitted if they are not suitable for the planned surgical 
procedure. For example, patients who will have surgery of the lumbar 
region, transurethral resections of the prostate, or procedures which 
use a vaginal approach are not taught to support their incisions. 
Information and additional activities may be included by the nurse at 
appropriate points. An instance might be that of the patient who is 
expected to have a catheter for continuous urinary drainage after 
surgery. The nurse could assure him that the activities should be 
done as taught and he need only be careful to avoid pulling on the 
-143- 
tubing when exercising or turning. 
A consistent approach, by all nursing staff, to patients re¬ 
garding their postoperative activities will serve to prevent confusion 
due to conflicting instructions. An in-service program using the film 
with the hospital’s own specific instruction plans might be helpful to 
enhance the quality of patient care. Postoperative follow-up nursing 
care is essential for optimum benefits. 
When teaching patients with this film, it is recommended that 
a projector be used that permits the nurse to stop the film. This 
allows the patient to practice each activity immediately and the nurse 
can give pertinent instructions and suggestions. The projector should 
let the nurse rewind any section of the film if desired and show it to 
the patient again for clarification. It should be possible to omit any 
section by running that section through the projector without its being 
shown on the screen. Placing the projector, an extension cord, and a 
small viewing screen on a wheeled table (with a top approximately the 
size of an overbed stand) will save time for the nurse in taking the 
film to the patient. Such a stand would eliminate the alternative of 
having to remove and then replace items from the patient's table in 
his room. 
There are other possibilities for using the film. Teaching 
small groups of patients might be considered. A convenience for 
patients and nurses would be to provide brief printed instructions to 
"144- 
each patient for later reference after teaching with the film. This 
could list the activities to be performed including how often and how 
many times to do each activity. Nursing students might benefit from 
studying the film and guide in preparation for teaching patients. 
A basic plan used in one hospital included such ideas as: 
1. Patients were taught in their rooms during the evening 
before scheduled surgery. The nurse planned to show the film and 
teach while family was present if possible because of the support and 
encouragement that informed family members may provide the patient. 
Sometimes this was not possible due to the limited time for visiting 
or because there was no family member or close friend available. 
2. "To help you get well faster after your surgery" was the 
central reason given patients for doing the exercises postoperatively. 
All staff agreed that a statement of this nature was suitable. Some 
felt patients should be told that another reason was to help prevent 
complications such as pneumonia. Patients sometimes commented that 
they thought the activities should help reduce "gas pains" and aching 
legs. 
The first scene in the film, after the main title, shows a 
patient in bed with the siderails up. This serves to orient the 
patient to what he will be viewing, and provides an opportunity to 
mention, "The siderails will be up when you first return from surgery. 
You may feel sleepy and be unsure of where the edge of the bed is due 
-145- 
to medications." 
The nurse may wish to suggest to the patient that he try prac 
ticing each activity while watching the film. After the patient 
watches each activity, the film is stopped. Verify that the patient 
can correctly perform the activity by watching him practice either 
during or after the film scene. Encourage and offer suggestions 
whenever indicated. State the number of times, frequency, and so on, 
for each activity. Answer questions and add any special instructions 
-146- 
BASIC ACTIVITIES 
Basic Activity: Exercise feet and lower legs. 
Film Titles for Activity: (1) FEET - PULL AND PUSH 
(2) FEET - MAKE A CIRCLE 
Approx. Film Time for Titles and Scenes: 1 min. 34 sec. 
Contraindications: Usually none for common types of surgery. Some 
types of vascular surgery, existing thrombophlebitis, some surgery on 
the lower extremities. 
Begin: On own initiative as soon as "awake" after surgery. Nurse to 
remind and assist until patient’s performance is correct and dependable. 
Number of Times: 4 to 6 complete movements with each foot for each 
of the two exercises shown. 
Frequency: Every 1 to 2 hours except when asleep at night (unless 
surgeon orders to continue throughout each twenty-four hours). 
Continue: Until up and walking about several hours each day. 
Position of Patient: Any position ranging from flat in bed to sitting 
in a chair. 
Film Shows: 
(A) FEET - PULL AND PUSH (See Figure 1, page 147). 
1. Firmly and slowly pull (flex) feet and toes toward chin 
as far as possible. 
2. Firmly and slowly push (extend) feet and toes toward 
foot of bed. 
3. Keep legs straight and knees on bed. 
4. Relax. 
5. Repeat, using both feet together, six times. 
(B) FEET - MAKE A CIRCLE (See Figure 2, page 147). 
1. Position feet about ten inches apart. 
-147- 
Figure 2. Feet - Make A Circle 
-148- 
2. Firmly and slowly rotate feet on ankle joint so toes make 
a large circle. 
3. Relax, 
4. Both feet together. 
5. Circle to right three times, then to left three times for 
a total of six complete rotations for each foot. 
Additional Considerations: 
These may be performed using both feet together, or with each foot 
alone. 
Note: Toes may usually be wiggled vigorously even when other 
movements of feet and legs are not possible or appropriate. 
Benefits to Patient: 
1. Stimulates circulation by compressing the veins in the lower 
legs and increases the return blood volume flow. 
2. Helps prevent venous stasis and thus lessens the possibility 
of thrombus formation in the lower extremities. 
3. Helps prevent complications such as thrombophlebitis and 
pulmonary embolism. 
4. Decreases "tired feeling" in legs; may help prevent leg 
aches or cramps. 
5. Reduces possibility of ankle joint stiffness due to inactivity. 
Basic Activity: Exercise Legs. 
Film Title for Activity: LEGS - PULL AND PUSH 
Approx. Film Time for Title and Scenes: 1 min. 25 sec. 
Contraindications: Usually none for common types of surgery. May need 
to restrict movements if certain types of equipment are attached to 
the patient’s leg (e.g., a cystocath). Some types of vascular surgery, 
existing thrombophlebitis, and some surgery on the lower extremities 
and hips may be contraindications. Check with surgeon whenever there 
is any question. 
-149- 
Begin: Immediately after surgery. On own initiative as soon as 
"awake" after surgery. Nurse to remind and assist until patient’s 
performance is correct and dependable. 
Number of Times: 4 to 6 complete movements with each leg. 
Frequency: Every 1 to 2 hours; oftener, if desired. 
Continue: Until up and walking about several hours a day. 
Position of Patient: Supine is preferable, but may be accomplished 
to some extent while lying on side. 
Film Shows: 
A. Flexion and extension of each leg (Figure 3, page 150). 
1. Patient is supine. 
2. Slide foot along bed toward buttock to bend knee. 
3. Return leg to horizontal. 
4. Perform with each leg alternately, like riding a bicycle. 
5. Relax. 
B. An optional method (Figure 5, page 151). 
1. Patient is lying on her side. 
2. Same basic motions as in "A" above, but with upper leg only. 
3. Will not be useful for all patients. 
Additional Considerations: 
A. An alternate method, not shown in the film, is shown in Figure 
4. page 150. 
1. Patient supine. 
2. Flex and extend both legs together at the same time. 
3. Slide feet along bed toward buttocks to bend knees. 
4. Return both legs to horizontal. 
5. Relax. 
B. Patients with indwelling catheters attached to drainage tubing 
may need reassurance that they should do this exercise. Remind 
them simply to avoid pulling on the tubing. 
-150- 
Figure 4. An Alternative: Legs - Pull and Push (Both legs together), 
(Not shown in film) 
-151- 
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-152- 
Benefits to Patient: 
1. All of those listed under "Exercise Feet." 
2. Increases respiratory activity. 
3. May help reduce abdominal discomforts. 
4. Reduces possibility of hip and knee joint stiffness due to 
inactivity. 
5. May promote subsequent relaxation of muscles and thus a 
decrease in postoperative pain. 
6. Prevents loss of muscle tone and muscle weakness. 
7. Often improves patient's morale; may help stimulate appetite. 
8. Reduces the loss of nitrogen and calcium. 
Basic Activity: Deep Breathing 
Film Title for Activity: DEEP BREATHE 
Approx. Film Time for Title and Scenes: 1 min. 
Contraindications: Usually none. However, deep breathing should not 
be done too rapidly, or excessively to the point of hyperventilation. 
Begin: Immediately after surgery. On own initiative as soon as 
"awake" after surgery. Nurse to remind and assist until patient's 
performance is correct and dependable. 
Number of Times: 4 to 6 complete cycles of inhale-exhale-relax. 
Frequency: Every hour is preferable. 
Continue: Until up and walking about several hours a day. 
Position of Patient: Sitting, or semi-sitting, at least every two 
hours. May be done while lying supine, or on side, every other hour. 
May also be done while standing. 
-153- 
Film Shows: 
1. Patient in bed with head of bed raised to a semi-sitting 
positon. 
2. Deep breathing is combined with arm exercises in film (Figure 
6, page 154). 
3. Exhale and place hands on mid-chest. 
4. Take a slow, deep, inhalation, conscously expanding abdomen 
and chest fully while extending both arms up and outward. 
5. Slowly exhale as completely as possible by compressing both 
abdominal and chest muscles, while lowering hands to rest on 
mid-chest. 
6. Relax. 
7. Total of six times is shown. 
Additional Consideration: 
1. May omit raising and lowering of arms if desired unless these 
are ordered by surgeon. If this method is used, the patient 
would place his hands on abdomen just above the umbilicus. 
(Figure 7, page 154.) This is not shown in the film. 
2. The nurse may help emphasize correct technique by placing her 
hand on the patient's abdomen below the diaphragm. Patients 
should also be taught this manner of checking for themselves. 
3. Shallow respirations are often a problem when patient has 
experienced upper abdominal surgery, when tight binders, 
dressings, or abdominal distention limits ability of diaphragm 
to move, and in very ill or elderly patients. 
4. Patients experiencing thoracic surgery and some types of 
abdominal surgery (e.g., cholecystectomy) will often need 
assistance by the nurse (or a family member of friend), when 
first attempting to deep breathe. 
5. Skillful nursing observation and appropriate timing of the 
administration of analgesics will be helpful. 
-154- 
Figure 6. Deep Breathe and Raise Arms While Inhaling 
Figure 7. An Alternative: Deep Breathe, Hands On Abdomen 
(Not in film) 
-155- 
6. If intermittent positive pressure breathing (IPPB) treatments 
are ordered, explain to patient that there may be slight 
differences in their exact movements, but the purpose is 
similar. Remind patients that they are expected to do these 
exercises regularly between the IPPB treatments. 
Benefits to Patient: 
1. Maintains ability of lungs to expand and stimulates more 
effective ventilation. 
2. Increases oxygen supply to body. 
3. May help mobilize secretions so they can be coughed up more 
easily. 
4. Improves venous return to the heart. 
5. May help improve morale and promote relaxation. 
Basic Activity: Deep Coughing 
Film Title for Activity: DEEP COUGH 
Approx. Film Time for Title and Scenes: 40 sec. 
Contraindications: Usually none for common types of surgery. Deep 
coughing should not be done by patients who have had surgery of the 
brain, eye, or certain spinal procedures. The surgeon should be 
consulted whenever there is any question. Occasionally, deep cough 
may be omitted for some patients with herniorrhaphies. 
Begin: Soon after surgery. On own initiative as soon as "awake" 
after surgery, but nurse should be with the patient at least the first 
time. Nurse will need to remind and assist patients until their 
performance is correct and dependable. 
Number of Times: 2 to 3. 
Frequency: Every 1 to 2 hours. 
Continue: Until lungs are clear. 
-156- 
Position of Patient: Sitting, or semi-sitting. May also be done while 
standing. 
Film Shows: 
1. Patient in bed in semi-sitting position (Figure 8, page 157). 
2. Place hands in position to support incision (or on abdomen 
above umbilicus). 
3. Deep inhalation. Air is pulled into lungs using abdominal 
and chest muscles. This causes abdomen to rise, diaphragm is 
pulled down, and chest expands. 
4. Momentary closure of glottis (". . . hold your breath a mo¬ 
ment.") 
5. Firm contraction of the abdominal and chest muscles to produce 
a sudden, forceful exhalation through the open mouth which 
pushes air and/or mucus out of the lungs. 
6. Relax. 
Additional Considerations: 
1. To be effective in removing secretions, this must be a deep 
cough. 
2. Avoid shallow coughing which is not only ineffective, but may 
be irritating to the throat. 
3. Patients may be reluctant to deep cough due to discomfort. 
Assistance and encouragement by the nurse is essential. 
Appropriate timing of analgesics, and support of the patient’s 
incision are often helpful. 
4. This activity may be tiring for patients. 
5. If patient is to have an inguinal herniorrhaphy, he should 
always support the incision when coughing. 
Benefits to Patient: 
1. Prevention of pulmonary complications such as atelectasis 
or pneumonia by helping to remove accumulated tracheobronchial 
-157- 
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-158- 
and pulmonary secretions and prevent the formation of mucous 
plugs in alveoli. 
2. Secondary benefit is to improve pulmonary ventilation. 
Basic Activity: Support of Incision by the Patient. 
Film Title for Activity: SUPPORT INCISION 
Approx. Film Time for Title and Scenes: 45 sec. 
Contraindications: Usually none, but is not suitable for all patients. 
Begin:, As necessary, or desired. 
Number of Times and Frequency: (1) Whenever indicated, e.g., patients 
with hernia repairs will need to support their incision when coughing, 
turning, or getting out of bed. (2) If helpful to the patient when he 
is coughing, or turning in bed. 
Continue: (1) In the case of patients with hernia repairs, until the 
surgeon states that this is no longer necessary. (2) Other patients, 
until no longer needed or helpful. 
Position of Patient: Will range from flat in bed to standing. 
Film Shows: 
1. Patient semi-sitting in bed. (Figure 9, page 159'.) 
2. Shown in sequence are: use of arms alone, and arms with a 
pillow or bath blanket, for an upper right quadrant incision. 
Additional Considerations: 
1. May also teach correct use of hands alone for some patients, 
e.g., when a lower midline incision is anticipated. Teach 
patient to place hands on either side of incision while exert¬ 
ing firm pressure downward and toward incision. (Figure 9-C, 
page 159.) 
2. Use of upper thigh to support incision may also be taught to 
patients expecting inguinal or femoral herniorrhaphies. 
(Figure 9-D, page 159.) 
-159- 
Figure 9. Support Incision. A, Using a pillow. B, Using a folded 
bath blanket or towel. C, With hands placed on either side of incision 
while exerting firm pressure downward and toward incision. D, Holding 
thigh firmly against incision for patients with inguinal herniorrhaphy. 
(C and D are not shown in the film.) 
-160- 
3. In most instances, patients should be encouraged to use what¬ 
ever method they find to be the most effective for them. 
Benefits to Patient: 
1. Basically, comfort and thus an increase in ability to deep 
breathe, deep cough, and turn. 
2. Prevention of undue strain on hernia repair. 
Basic Activity: Turning of entire body by the patient himself. 
Film Title for Activity: TURNING YOURSELF 
1. BACK TO SIDE 
2. SIDE TO BACK 
Approx. Time for Title and Scenes: 1 min. 
Contraindications: Usually none for common types of surgery. Check 
with surgeon if any question in relation to other procedures. 
Begin: Immediately after surgery. On own initiative as soon as 
"awake." Nurse may need to provide encouragement and some assistance 
at first. 
Number of Times: One complete change of position. 
Frequency: Every 1 to 2 hours at first; later, every 2 hours. 
Continue: Until up and walking about several hours a day. 
Position of Patient: Will vary, but bed should be flat, or nearly 
so, to facilitate turning and good body alignment. 
Film Shows: 
A. Back to Side: 
1. Patient supine and turning to the right. (Figure 10, 
page 162.) 
2. Left knee is bent and left foot placed flat on bed. 
-161- 
3. Right arm and hand are used to support abdominal incision. 
4. Patient pushes with left foot, grasps side rail with left 
hand and rolls onto right side. 
5. Patient assumes positions which avoid undue pressure on 
arm next to bed, and/or restriction of chest expansion. 
(Figure 11, page 163.) 
B. Side to Back: 
1. Patient is lying on right side, upper leg is straightened. 
(Figure 12, page 164.) 
2. Arm next to bed supports incision. Patient places fist of 
upper arm firmly on the bed at a right angle, and pushes 
to roll onto back. 
3. Assume position of comfort with good body alignment. 
Additional Considerations: 
1. Patient may need to move slightly to the opposite side of the 
bed before attempting to turn. 
2. When patient is lying on his side, he should position himself 
so as to avoid undue pressure on the lower arm. It is also 
important for the patient to be able to expand his chest freely. 
3. Some patients may require pillows or bath blankets for support 
when lying on their side. 
Benefits to Patient: 
1. Includes most of the benefits listed under "exercise feet" 
and "exercise legs." 
2. Prevents pooling of secretions in lungs or body cavities. 
3. Prevents prolonged pressure on the skin in any one area. 
4. Helps relieve aching muscles. 
5. May help prevent, or reduce abdominal discomfort and disten¬ 
tion due to "gas." 
-162- 
Figure 10. Turning Yourself - Back to Side. A, Bend opposite knee 
placing foot flat on bed. (Support incision if desired.) B, Grasp 
siderail and roll over while pushing with opposite foot. 
-163- 
Figure 11. Two examples of positions after turning from back to side 
which avoid pressure on lower arm. A, Lower arm under pillow (or on 
bed in front of patient).- B, Sims* position. 
-164- 
Figure 12. Turning Yourself - Side to Back. A, Straighten upper leg 
if desired, support incision with arm next to bed, place fist or palm 
of upper arm firmly on the bed and push to roll onto back. B, On back 
with body straight. 
-165- 
Closing scene shows patient semi-sitting in bed and runs 
4 seconds. 
Before Leaving the Patient 
1. Reassure patient that "Nurses will remind and help you at 
first when you’re still sleepy." 
2. When activities areata be continued throughout the night, 
explain that the nurses will be waking him up to do them. 
3. If printed information is to be provided the patient, 
incorporate this into the instructions. 
4. Leave patient as comfortable as possible. 
Perhaps most important for the nurse is to keep in mind these 
activities are only one segment of her surgical patient-teaching 
responsibilities. 
-166- 
APPENDIX B 
LIST OF BASIC EQUIPMENT NEEDED FOR SUPER-8mm FILM PRODUCTION 
AND PROJECTION WITH COST ESTIMATES 
Item 
Estimated 
Minimum Cost* 
I. Production 
Basic 
1. Super-8mm Movie Camera with zoom 
lens and automatic light 
exposure meter $ 150.00 
2. Tripod with swivel head 20.00 
3. Off camera photoflood lights (2) 50.00 
4. Editor and Splicer 25.00 
Sub Total $ 245.00 
Recurring 
1. Batteries for camera 2.50 
2. Color Tran (or others) lamps for 
photoflood lights 20.00 
3. Super-8mm color film, 50 ft. rolls @ 3.20 
4. Developing of film (includes 
postage), 50 ft. rolls 0 2.00 
5. Splicing Tape or cement 1.00 
Sub Total $ 28.70 
Variable 
1. Feltboard and letters for titles 
(or other devices) 30.00 
2. Extension cords with three-way plugs — . 
Sub Total i. 30.00 
TOTAL $ 303.70 
-167- 
APPENDIX B (continued) 
Item 
II. Projection 
A. Basic 
1. Super-Smm movie Projector 
(Ektagraphic 120) 
2. 100 ft. cartridge (includes reel) 
3. Small screen 
4. Wheeled table with shelves 
(approx. 15" x 34") 
5. Extension cord with 3-way plug 
Sub Total 
B. Recurring 
1. Bulbs for Projector 
TOTAL 
*These costs will vary widely depending on such factors 
equipment purchased and the source of supply. 
III. Actual cost of the film used in this study 
A. 4 rolls of Super-Smm color film 
@ $3.20/50 ft. 
B. Developing and Postage 
C. Splicing Tape 
Sub Total 
D. 100 ft. cartridge and reel 
Estimated 
Minimum Cost* 
$ 135.00 
.90 
16.00 
50.00 
5.00 
$ 206.90 
(5.00-15.00) 
$ 221.90 
as the kind of 
$ 12.80 
8.76 
. .50 
$ 22.16 
 .90 
TOTAL $ 23.06 
-168 
APPENDIX C 
DATA COLLECTION TOOL 
Group 1 
Group 2 
xExercises ordered by Dr.   
Exercises as nursing measure  
Surgery  
Discharge Day  
Number:  
EVALUATION OF PATIENT'S BEHAVIOR POSTOPERATIVELY IN TERMS OF SELECTED ACTIVITIES 
Will the Individual who is caring for this patient on each shift please make a 
check (t-O beside the statement which you believe Indicates most accurately this 
patient’s behavior for each Item listed. 
Op. Day P.0. 1 P.0. 2 P.0. 3 P.0. 4 P.0. 5 P.0. 6 
Date 
Shift 7-J|J-ll|ll-7 7-j|3-ll|||-7 7-3tJ-lllll-7 7-j|3-ll|ll-7 7-3l3-lllM-7 7-3l3-/(ll/-7 7-3 l3-/l|ll-7 
EXERCISE FEET (At least twice q 2 hrs.) 
1. Without reminding by nurse 
2. Good when reminded by nurse 
3. Poor when reminded by nurse 
EXERCISE LEGS (At least twice 
1. Without reminding by nurse 
2. Good when reminded by nurse 
3. Poor when reminded by nurse 
2 hrs.) 
DEEP BREATHE (At least twice q 2 hrs.) 
1. Without reminding by nurse 
2. Good when reminded by nurse 
3. Poor when reminded by nurse 
DEEP COUGH (At least twice q 2 hrs.) 
1. Without reminding by nurse 
2. Good when reminded by nurse 
3. Poor when reminded by nurse 
SUPPORT INCISION (When coughing or turning if indicated, 
1. Without reminding by nurse 
2. Good when reminded by nurse 
3. Poor when reminded by nurse 
or helpful.) 
TURN IN BED (At least once q 2 hrs.) 
1. Without reminding by nurse 
2. Good when reminded by nurse_ 
3. Poor when reminded by nurse! 
Check below to Indicate title of 
R.N. 
L.P.N.   
W.A. ; ORD. 
verson making checks above. 
Patient was taught how to do exercises: 
Preoperatively Yes* No 
Postoperatively (k' mark I I I I I I I 1 1 I I I I I I I I 1 I I I 
Teaching done by: Dr. 
R.N. 
L.P.N. 
W.A.: ORD. 
Approximate time spent teaching patient how to do exercises: preoperatively and/or postoperatively: 
(Total spent per shift.)1* 1 1 1 1 1 1 1 1 1 1 1 1 1 1 till 1^^ 
Approximate time spent reminding 
(Total spent per shift.) 
patient to do exercises. 
rf r i i i i i i i i r'i i r r~iH r i T I 
Comments from staff are welcome. Please use the back of this sheet to write anything 
you feel Is relevant. (Indicate your title; you need not sign your name unless you 
wish to.) Thank you for your help. 
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LITERATURE CITED 
LITERATURE CITED 
A. BOOKS 
Abdellah, Faye G., and Eugene Levine. Better Patient Care Through 
Nursing Research. London: The Macmillan Company, Collier- 
Macmillan Limited, 1966. 
American College of Surgeons, Committee on Pre- and Postoperative 
Care. Manual of Preoperative and Postoperative Care. 
Philadelphia: W. B. Saunders Company, 1967. 
ANA Clinical Sessions, American Nurses1 Association 1968 Dallas. 
New York: Appleton-Century-Crofts, 1968. 
Barbata, Jean C., Deborah M. Jensen, and William G. Patterson. 
A Textbook of Medical-Surgical Nursing. New York: G. P. 
Putnam*s Sons, 1964. 
Beland, Irene L. Clinical Nursing: Pathophysiological and Psycho¬ 
social Approaches. 2nd ed. New York: The Macmillan Company, 
1970. 
Brunner, Lillian S., et al. Textbook of Medical-Surgical Nursing. 
2nd ed. Philadelphia: J. B. Lippincott Company, 1970. 
Corey, Stephen M. Action Research To Improve School Practices. 
New York: Bureau of Publications, Teachers College, Columbia 
University, 1953. 
Cronbach, Lee J. Educational Psychology. 2nd ed. New York: Harcourt, 
Brace and World, Inc., 1963. 
Dale, Edgar. Audiovisual Methods in Teaching. 3rd ed. New York: 
Dryden Press, Holt, Rinehart and Winston, Inc., 1969. 
Davis, Loyal (ed.). Christopher’s Textbook of Surgery. 7th ed. 
Philadelphia: W. B. Saunders Co., 1960. 
Dunn, Halbert L. High-Level Wellness. Virginia: R. W. Beatty, Ltd., 
1961. 
-182- 
Edwards, Allen L. Statistical Methods. 2nd ed. New York: Holt, 
Rinehart and Winston, Inc., 1967. 
Erickson, Carlton W. H. Fundamentals of Teaching With Audiovisual 
Technology. London: Collier-Macmillan Ltd., The Macmillan 
Co., 1965. 
Falls, Harold B. (ed.). Exercise Physiology. New York: Academic 
Press, 1968. 
Fischer, Valentina B., and Arlene F. Connolly. Promotion of Physical 
Comfort and Safety. Dubuque, Iowa: Wm. C. Brown Company 
Publishers, 1970. 
Gragg, Shirley Hawke, and Olive M. Rees. Scientific Principles in 
Nursing. 6th ed. St. Louis: The C. V. Mosby Company, 1970. 
Guyton, Arthur C. Textbook of Medical Physiology. 3rd ed. 
Philadelphia: W. B. Saunders Co., 1966. 
Hilgard, Ernest R., and Gordon H. Bower. Theories of Learning. 
3rd ed. New York: Appleton-Century-Crofts, Educational Division, 
Meredith Corporation, 1966. 
Jaco, E. Gartly (ed.). Patients, Physicians and Illness. Glencoe, 
Illinois: The Free Press, 1958. 
Janis, Irving L. Psychological Stress. New York: John Wiley and 
Sons, Inc., 1958. 
Johnston, Dorothy F. Total Patient Care Foundations and Practice. 
2nd ed. St. Louis: The C. V. Mosby Co., 1968. 
Jourard, Sidney M. The Transparent Self. New York: Van Nostrand 
Reinhold Co., 1964. 
Kemp, Jerrold E. Planning and Producing Audiovisual Materials. 2nd 
ed. California: Chandler Publishing Company, 1968. 
Lewis, Garland K. Nurse-Patient Communication. Dubuque, Iowa: 
Wm. C. Brown Co., 1969. 
Ley, P., and M. S. Spelman. Communicating With the Patient. 
St. Louis: Warren H. Green, Inc., 1967. 
-183- 
Lysaught, Jerome P., Director, National Commission for the Study of 
Nursing and Nursing Education. An Abstract for Action. 
New York: McGraw-Hill Book Company, 1970. 
McBride, Otis J. Lecture Series and Workshop Guide, [n.p.] 3M 
Company, Visual Products Department, 1965, Lecture 1 [pp. 1-2]. 
McCutcheon, Maureen. Care of the Patient With Common Medical-Surgical 
Disorders: A Textbook for Nurses. New York: McGraw-Hill Book Co., 
1970. 
Meyer, Burton, and Loretta E. Heidgerken. Introduction to Research in 
Nursing. Philadelphia: J. B. Lippincott Co., 1962. 
Moidel, Harriet Coston, et al. Nursing Care of the Patient With 
Medical-Surgical Disorders. New York: McGraw-Hill Book Co., 1971. 
Movies with a Purpose. [New York]: Motion Picture and Education 
Markets Division, Eastman Kodak Company, [1970]. 
The National Survey of Audiovisual Materials for Nursing, 1968-1969. 
New York: Educational Services Division, The American Journal of 
Nursing Company, 1970. 
Phillips, Jeanne S., and Richard F. Thompson. Statistics for Nurses: 
The Evaluation of Quantitative Information. New York: The 
Macmillan Company, 1967. 
Redman, Barbara Klug. The Process of Patient Teaching in Nursing. 
St. Louis: The C. V. Mosby Co., 1968. 
Rogers, Martha E. An Introduction to the Theoretical Basis of Nursing. 
Philadelphia: F. A. Davis Co., 1970. 
Roscoe, John T. Fundamental Research Statistics for the Behavioral 
Sciences. New York: Holt, Rinehart and Winston, Inc., 1969. 
Secor, Jane. Patient Care in Respiratory Problems, (Saunders Mono¬ 
graphs in Clinical Nursing - 1). Philadelphia: W. B. Saunders 
Co., 1969. 
Selltiz, Claire, et al. Research Methods in Social Relations, rev. 
ed. [New York]: Henry Holt and Co., 1959. 
-184- 
Shafer, Kathleen Newton, et al. Medical-Surgical Nursing, 4th ed. 
St. Louis: The C. V. Mosby Co., 1967. 
Simmons, Leo W., and Virginia Henderson. Nursing Research: A Survey 
and Assessment. New York: Appleton-Century-Crofts, 1964. 
Smith, Dorothy W., Carol P. Hanley Germain, and Claudia D. Gips. 
Care of the Adult Patient: Medical-Surgical Nursing. 3rd ed. 
Philadelphia: J. B. Lippincott Co., 1971o 
Tickton, Sidney G. (ed„). To Improve Learning, An Evaluation of 
Instructional Technology. 2 vols. New York: R. R. Bowker 
Co., 1970-71. 
Travelbee, Joyce. Interpersonal Aspects of Nursing. 2nd ed. 
Philadelphia: F. A. Davis Co., 1971. 
Wittich, Walter Amo, and Charles Francis Schuller. Audiovisual 
Materials: Their Nature and Use. 4th ed. New York: Harper 
and Row, Publishers, 1967. 
B. PERIODICALS 
Abdellah, Faye G. "Overview of Nursing Research 1955-1968, Part I," 
Nursing Research, IXX (January-February, 1970), 6-17. 
  . "Overview of Nursing Research 1955-1968, Part II," 
Nursing Research, IXX (March-April, 1970), 151-162. 
 . "Overview of Nursing Research 1955-1968, Part III," 
Nursing Research, IXX (May-June, 1970), 239-252. 
Allen, William H. "Media Stimulus and Types of Learning," Audiovisual 
Instruction, XII (January, 1967), 27-31. 
Carnevali, Doris L. "Preoperative Anxiety," American Journal of 
Nursing, LXVI (July, 1966), 1536-1538. 
Cassady, June R., and John Altrocchi. "Patients’ Concerns About 
Surgery," Nursing Research, IX (Fall, 1960), 219-221. 
-185- 
Coller, Frederick A., and Marion S. DeWeese. "Preoperative and Post¬ 
operative Care," Journal of the American Medical Association, 
CXLI (November 5, 1949), 641-646. 
Committee on Nursing. "Medicine and Nursing in the 1970's: A Position 
Statement," The Journal of the American Medical Association, 
CCXIII (September 14, 1970), 1881-1883. 
Dodge, Joan S. "Factors Related to Patients' Perceptions of Their 
Cognitive Needs," Nursing Research, XVIII (November-December, 
1969) , 502-513. 
Dripps, Robert D., and Ralph M. Waters. "Nursing Care of Surgical 
Patients: Part I. The 'Stir-up'," The American Journal of Nursing, 
XLI (May, 1941), 530-534. 
Egbert, Lawrence D., et al. "Reduction of Postoperative Pain by 
Encouragement and Instruction of Patients," New England Journal 
of Medicine, CCLXX (April 16, 1964), 825-827. 
Plane, C., V. V. Kakkar, and M. B. Clarke. "Postoperative Deep-Vein 
Thrombosis, Effect of Intensive Prophylaxis," The Lancet, I 
(March 8, 1969), 477-479. 
Graham, Lois E., and Elizabeth Myers Conley. "Evaluation of Anxiety 
and Fear in Adult Surgical Patients," Nursing Research, XX 
(March-April, 1971), 113-122. 
Hall, Keith A. "Research Papers: 1971," Audiovisual Instruction, 
XVI (June/July, 1971), 42-44. 
Hearly, Kathryn M. "Does Preoperative Instruction Make a Difference?" 
American Journal of Nursing, LXVIII (January, 1968), 62-67. 
Johnson, Barbara A., Jean E. Johnson, and Rhetaugh G. Dumas. 
"Research in Nursing Practice: The Problem of Uncontrolled 
Situational Variables," Nursing Research, IXX (July-August, 
1970) , 337-342. 
Johnson, Jean E., James M. Dobbs, Jr., and Howard Leventhal. 
"Psychosocial Factors in the Welfare of Surgical Patients." 
Nursing Research, IXX (January-February, 1970), 18-28. 
-186- 
Johnson, Jean E., Rhetaugh G. Dumaa, and Barbara A. Johnson. 
"Interpersonal Relations: The Essence of Nursing Care," Nursing 
Forum, VI (No. 3, 1967), 324-334. 
Kelly, Mary M. "Exercises for Bedfast Patients," American Journal 
of Nursing, LXVI (October, 1966), 2209-2213. 
Lambertsen, Eleanor C. "Nurses Must be Teachers and Must Know These 
Principles," Modem Hospital, CX (February, 1968), 126. 
Leithauser, Daniel J. "Early Ambulation," The American Journal of 
Nursing, L (April, 1950), 203-206. 
 , Louis Gregory, and Stella M. Miller. "Immediate Ambulation 
After Extensive Surgery," The American Journal of Nursing, 
LXVI (October, 1966), 2207-2208. 
 , et al. "Prevention of Embolic Complications From Venous 
Thrombosis After Surgery," Journal of the American Medical 
Association, CXLVII (September 22, 1951), 300-303. 
Levine, Dale C., and June P. Fiedler. "Fears, Facts, and Fantasies 
About Pre- and Postoperative Care," Nursing Outlook, XVIII 
(February, 1970), 26-28. 
Lindeman, Carol A., and Betty Van Aemam. "Nursing Intervention With 
the Presurgical Patient—The Effects of Structured and Un¬ 
structured Preoperative Teaching," Nursing Research, XX (July- 
August, 1971), 319-332. 
MacArthur, Christine. "We Teach—Do Our Patients Learn?" The 
Canadian Nurse, LV (March, 1959), 205-210. 
McLean, James C. "How to Use Audiovisual Communications," Modern 
Hospital, CVI (February, 1966), 97-100. 
Mezzanotte, Elizabeth Jame. "Group Instruction in Preparation for 
Surgery," American Journal of Nursing, LXX (January, 1970), 
89-91. 
Monteiro, Lois A. "Notes on Patient Teaching—A Neglected Area," 
Nursing Forum, III (No., 1964), 26-33. 
Myers, Robert S. "Here Are 50 Most Common Operations," Modern 
Hospital, CVI (January, 1966), 122. 
-187- 
Pohl, Margaret L. "Teaching Activities of the Nursing Practitioner," 
Nursing Research, XIV (Winter, 1965), 4-11. 
"Prevention of Venous Thrombosis," The Lancet, I (February 21, 1970), 
395-396. 
Sherman, Roger T. "Total Patient Care From a Surgeon^ Point of 
View," Nursing Forum, IV (No. 3, 1965), 27-32. 
Skipper, James K., Daisy L. Tagliacozzo, and Hans 0. Mauksch. "What 
Communication Means to Patients." American Journal of Nursing, 
LXIV (April, 1964), 101-103. 
Storlie, Frances. "A Philosophy of Patient Teaching," Nursing 
Outlook, IXX (June, 1971), 387-389. 
Weiler, Sister M. Cashel. "Postoperative Patients Evaluate Pre¬ 
operative Instruction." American Journal of Nursing, LXVIII 
(July, 1968), 1465-1467. 
Weiss, Stephen M. "Psychosomatic Aspects of Symptom Patterns Among 
Major Surgery Patients." Journal of Psychosomatic Research, 
XIII (Pergamon Press, 1969), 109-112. 
Wolfer, John A., and Carol E. Davis. "Assessment of Surgical 
Patients' Preoperative Emotional Condition and Postoperative 
Welfare," Nursing Research, IXX (September-October. 1970). 
402-414. 
-188- 
LITERATURE CONSULTED 
LITERATURE CONSULTED 
A. BOOKS 
Alexander, Edythe Louise, et al. Care of the Patient in Surgery 
Including Techniques. 4th ed. St. Louis: The C. V. Mosby Co., 
1967. 
Basic Titling and Animation for Motion Pictures. 2nd ed. New York: 
Eastman Kodak Co., 1970. 
Berry, Edna Cornelia, and Mary Louise Kohn. Introduction to Operating 
Room Technique. 2nd ed. New York: McGraw-Hill Book Co., Inc., 
1960. 
Bigge, Morris L. Learning Theories for Teachers. New York: Harper 
and Row, 1964. 
Brown, Esther Lucile. Newer Dimensions of Patient Care. Parts 1, 2, 
and 3. New York: Russell Sage Foundation, 1961 - 1964. 
Dison, Norma Greenler. An Atlas of Nursing Techniques. St. Louis: 
The C. V. Mosby Co., 1967. 
Duff, Raymond S., and August B. Hollingshead. Sickness and Society. 
New York: Harper and Row, 1968. 
Eastman Kodak Company. How to Make Good Home Movies. New York: 
Eastman Kodak Company, 1966. 
Folta, Jeannette R., and Edith S. Deck. A Sociological Framework 
For Patient Care. New York: John Wiley and Sons, Inc., 1966. 
Fox, David J. Fundamentals of Research in Nursing. New York: 
Appleton-Century-Crofts, Division of Meredith Publishing Co., 
1966. 
Henderson, Virginia. The Nature of Nursing. New York: The Macmillan 
Co., 1966. 
Hoffman, Claire P., Gladys B. Lipkin, and Ella M. Thompson. 
Simplified Nursing. 8th ed. Philadelphia: J. B. Lippincott, 
1968. 
-190- 
Jour ard, Sidney M. The Transparent Self, rev. ed. New York: Van 
Nostrand Reinhold Co., 1971. 
Kozier, Barbara Blackwood, and Beverly Witter DuGas. Fundamentals 
of Patient Care. Philadelphia: W. B- Saunders Co., 1967. 
Leake, Mary J. A Manual of Simple Nursing Procedures. 4th ed. 
Philadelphia: W. B. Saunders Co., 1966. 
LeMaitre, George D., and Janet A. Finnegan. The Patient In Surgery. 
2nd ed. Philadelphia: W. B. Saunders Co., 1970. 
Levine, Myra Estrin. Introduction to Clinical Nursing. Philadelphia: 
F. A. Davis Co., 1969. 
Mascelli, Joseph V. (ed.). The Five C’s of Cinematography. Hollywood 
Cine/Graphic Publications, 1965. 
Matheney, Ruth V., et al. Fundamentals of Patient-Centered Nursing. 
2nd ed. St. Louis: The C. V. Mosby Co., 1968. 
Matzkin, Mryon A. Better Super 8 Movie Making. New York: American 
Photographic Book Publishing Co., Inc., 1967. 
McCormick, Thomas C., and Roy G. Francis. Methods of Research in the 
Behavioral Sciences. New York: Harper and Brothers, Publishers, 
1958. 
Miles, Matthew B. (ed.). Innovation in Education. New York: Bureau 
of Publications, Teachers College, Columbia University, 1964. 
Orlando, Ida Jean. The Dynamic Nurse-Patient Relationship. New York: 
G. P. Putnam*s Sons, 1961. 
Pohl, Margaret. Teaching Function of the Nurse Practitioner. 
Dubuque, Iowa: Wm. C. Brown Co., Publishers, 1968. 
Robinson, Lisa. Psychological Aspects of the Care of Hospitalized 
Patients. Philadelphia: F. A. Davis Co., 1968. 
Skipper, James K., and Robert C. Leonard (eds.). Social Interaction 
and Patient Care. Philadelphia: J. B. Lippincott Co.,1965. 
-191- 
Taylor, Calvin W., and Frank E. Williams (eds.)» Instructional Media 
and Creativity. New York: John Wiley and Sons, Inc., 1966. 
Thompson, Ella M., and Constance Murphy. Textbook of Basic Nursing. 
Philadelphia: J. B. Lippincott Co.,. 1966. 
Ujhely, Gertrude. Determinants of the Nurse-Patient Relationship. 
New York: Springer Publishing Co., 1968. 
Warren, Richard. Surgery. Philadelphia: W. B. Saunders Co., 1963. 
Wells, Charles, and James Kyle (eds.). Scientific Foundations of 
Surgery. New York: American Elsevier Publishing Co., Inc.^ 
1967. 
B. PERIODICALS 
Aasterud, Margaret. "Explanation to the Patient," Nursing Forum, 
II (No. 4, 1963), 36-44. 
Alt, Richard E. "Patient Education Program Answers Many Unanswered 
Questions,"’ Hospitals, XL (November 16, 1966), 76-78, 166. 
Brownsberger, Carl N. "Emotional Stress Connected With Surgery," 
Nursing Forum, IV (No. 4, 1965), 46-55. 
Carnes, Marion A. "Postanesthetic Complications," Nursing Forum, 
IV (No. 3, 1965), 46-55. 
Collart, Marie E., and Janice K. Brenneman. "Preventing Postoperative 
Atelectasis." American Journal of Nursing, LXXI (October, 
1971), 1982-1987. 
Dodge, Joan S. "How Much Should the Patient Be Told—And By Whom?" 
Hospitals, Journal of the American Hospital Association, 
XXXVII (December 16, 1963), 66-67, passim. 
Dumas, Rhetaugh Graves. "Psychological Preparation for Surgery," 
American Journal of Nursing, LXIII (August, 1963), 52-55. 
-192- 
Dumas, Rhetaugh Graves, and Barbara J. Anderson. "Psychological 
Preparation Beneficial—If Based on Individual's Needs," 
Hospital Topics, XLII (May, 1964), 79 passim. 
. , and Robert C. Leonard. "Effect of Nursing on the Incidence 
of Postoperative Vomiting; A Clinical Experiment," Nursing 
Research, XII (Winter, 1963), 12-15. 
Ellis, C. R. "Fundamental Breathing Exercises," Nursing Mirror, 
CXXX (February 20, 1970), 34-35. 
Hall, Benita L. "Human Relations in the Hospital Setting." Nursing 
Outlook, XVI (March, 1968), 43-45. 
Jones, F. L. "Increasing Postoperative Ventilation - A Comparison of 
Five Methods," Anesthesiology, XXIX (November-December, 1968), 
1212-1215. 
Leithauser, Daniel J. "Rational Principles of Early Ambulation," 
Journal of the International College of Surgeons, XII (May-June, 
1949), 368-374. 
 , and Louis Gregory. "Early Ambulation Initiated by a Three 
Stage Procedure After Extensive Surgery." Surgery, Gynecology 
and Obstetrics, CXVIII (June, 1964), 1273-1276. 
Long, C. I., K. Kopp, and J. M. Kinney. "Energy Demands During 
Ambulation in Surgical Convalescence," Surgical Forum, XX 
([n.m.], 1969), 93-94. 
Lynch, Joseph D., Reatha M. Struck, and Donald F. Werners. "Anxiety 
and Anxiety Reduction in Surgical Patients." AORN Journal, VI 
(July, 1967), 58-60. 
Mikulic, Mary Ann. "Reinforcement of Independent and Dependent 
Patient Behaviors by Nursing Personnnel: An Exploratory Study," 
Nursing Research, XX (March-April, 1971), 162-165. 
Moore, Francis D. "Adaptation of Supportive Treatment to Needs of the 
Surgical Patient," The Journal of the American Medical Association, 
CXLI (Novembers, 1949), 641-653. 
-193- 
Packard, Rose B., and Harriet Van Ess. "A Comparison of Informal and 
Role-delineated Patient-teaching Situationsj1' Nursing Research, 
XVIII (September-October, 1969), 443-446. 
Palmer, Irene Mary Sabelberg. "Perceptions of Patients to Imminent 
General Surgery." Doctoral dissertation, New York University, 
1963. Published on demand by University Microfilms, Ann Arbor, 
Michigan. 
Peitchinis, J. "Psychological Care of Patient Important to Surgery's 
Outcome," Hospital Topics, XLIII (November, 1965), 113-119. 
"Preoperative and Postoperative Physiotherapy," The Lancet, II 
(September 26, 1970), 646. 
Simmons, Leo W. "What is the Potential Role of the Nurse in Patient 
Care?" Nursing Outlook, X (February, 1962), 103-105. 
Streeter, Virginia. "The Nurse's Responsibility for Teaching 
Patients," The American Journal of Nursing, LIII (July, 1953), 
818-820. 
Ward, R. J., et al. "Evaluation of Postoperative Respiratory 
Maneuvers," Surgery, Gynecology and Obstetrics, CXXIII (July, 
1966), 51-54. 
Wemett, Mary F. "Study of the Use of Films as Self-instructional 
Tools," Nursing Research, XVI (Winter, 1967), 83. 
Zollinger, R. M, and R. Passi. "Observations on Pre- and Post¬ 
operative Care." American Journal of Surgery, CXII (November, 
1966), 716-720.