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An experimental study to compare the effectiveness of individual and group preoperative instruction Baines, Chinnama 1989

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AN EXPERIMENTAL STUDY TO COMPARE THE EFFECTIVENESS OF INDIVIDUAL AND GROUP PREOPERATIVE INSTRUCTION by CHINNAMA BAINES B.Sc.N. , Madras University, 1963 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in the School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1974 In presenting this thesis in partial fulfi lment of the requirements for an advanced degree at the University of Br i t ish Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for f inancial gain shall not be allowed without my written permission. Department of The University of Br i t ish Columbia Vancouver 8, Canada i i ABSTRACT AN EXPERIMENTAL STUDY TO COMPARE THE EFFECTIVENESS OF INDIVIDUAL AND GROUP PREOPERATIVE INSTRUCTION CHINNAMA BAINES The purpose of this study was to compare the effect ive-ness of individual and group preoperative instruction in deep breathing, coughing, and bed exercises. The major questions asked in this study were: Is group preoperative instruction in deep breathing, coughing, and bed exercises as effective as individual instruct ion, as measured by the postoperative performance of exercises, the incidence of post-operative complications, and the length of hospital stay? Is there a relationship between one or more of the selected characteristics of the subjects (age, sex, smoking habits, weight and type of incision) and the effectiveness of individual and group preoperative instruction as measured by the above variables? Using one surgical f loor of a general hospital , sixty adult surgical patients who met the c r i te r ia of the study, were alternately assigned by week to either individual or group preopera-tive instruction. Structured instruction in deep breathing, coughing, and bed exercises was instituted by the investigator and the pre-operative teaching nurse with the assistance of a booklet. The data i i i iv were collected by means of the patient prof i le sheet and the evaluation guide of performance too l . The null hypotheses of the study were tested by means of t test and chi-square test of significance. The results revealed no signif icant difference between the effectiveness of individual and group preoperative instruction. The null hypotheses were accepted with p = .05. On determining the relationship between the selected characteristics of the subjects and the effectiveness of individual and group instruct ion, no signif icant results were obtained. The results were similar in individual and group instruct ion. The major conclusions drawn from the findings of the study were: group preoperative instruction in deep breathing, coughing, and bed exercises is as effective as individual instruct ion; and group instruction is as effective as individual instruction for subjects, regardless of their age. It is implied from the findings of the study that, group preoperative instruction should be tr ied out in hospitals; and schools of nursing should include in their curriculum, the dyn-amics of small group method. A number of recommendations for future investigations were suggested. V ACKNOWLEDGEMENTS I am grateful to my committee members, Helen E l fe r t , the Chairman, and Sue Rothwell, for their many helpful suggestions and encouragements; to Jack Yensen for his invaluable assistance with s ta t i s t i ca l analysis; to Jean Ruest, the Nursing Director, for giving me permission to conduct the study; to Doreen Fleury and to Nette Nobbs for their cooperative support in carrying out this study. TABLE OF CONTENTS Page LIST OF TABLES X CHAPTER I. INTRODUCTION 1 THE PROBLEM. .' 3 Statement 3 Significance 3 DESCRIPTION OF THE STUDY 6 Objectives . 6 Hypotheses 7 Variables 8 Definition of Terms 11 Basic Assumptions 13 Limitations of the Study 14 I I . REVIEW OF THE LITERATURE 16 INDIVIDUAL INSTRUCTION 16 GROUP INSTRUCTION 20 PREOPERATIVE INSTRUCTION IN GENERAL 24 PREOPERATIVE INSTRUCTION IN DEEP BREATHING, COUGHING, AND BED EXERCISES 26 Importance of Instruction in Deep Breathing, Coughing, and Bed Exercises 26 Effective Performance of Deep Breathing, Coughing, and Bed Exercises 29 vi vi i CHAPTER - Page Effectiveness of the Preoperative Instruction in Deep Breathing, Coughing, and Bed Exercises 30 SUMMARY 33 III. METHODOLOGY 34 DEVELOPMENT OF THE TOOLS 34 The Preoperative Instruction Tools 34 The Data Collection Tools 36 Re l iab i l i t y and Val idity of the Tools 37 THE SETTING AND THE SAMPLE 39 The Setting 39 The Subjects 40 THE PROCEDURE 40 Staff Orientation 41 Institution of Preoperative Instruction . . . . . 41 Collection of Data 43 METHOD OF DATA ANALYSIS 44 SUMMARY 44 IV. ANALYSIS OF THE DATA 45 COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION TO THE SELECTED CHARACTERISTICS 45 Age . 46 Sex 47 Smoking Habits 47 Weight 48 v i i i CHAPTER Page Type of Incision 49 ANALYSIS IN RELATION TO HYPOTHESES 50 Hypothesis I 50 Hypothesis II 51 Hypothesis III 54 RELATIONSHIP BETWEEN THE SELECTED CHARACTERISTICS AND THE EFFECTIVENESS OF INDIVIDUAL AND GROUP INSTRUCTION 56 Relationship Between Selected Characteristics and the Performance of Exercises 56 Relationship Between Selected Characteristics and the Incidence of Complications 61 Relationship Between Selected Characteristics and the Length of Hospital Stay 61 SUMMARY 69 V. SUMMARY, FINDINGS, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS 70 SUMMARY 70 FINDINGS 72 CONCLUSIONS 75 IMPLICATIONS 78 RECOMMENDATIONS 79 BIBLIOGRAPHY 81 APPENDIXES A. The Preoperative Instruction Tools 81 B. The Data Collection Tools 120 ix APPENDIXES Page C. Tables of S tat is t i ca l Analysis 140 D. Canadian Average Weight for Height and Age . . . 124 LIST OF TABLES Table Page I. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY AGE 46 II. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SEX . . . . . . 47 III. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SMOKING HABITS . . . 48 IV. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY WEIGHT 49 V. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY TYPE OF INCISION 50 VI. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AMD GROUP INSTRUCTION BY THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING AND BED EXERCISES 52 VII. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS 53 VIII. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY LENGTH OF HOSPITAL STAY 55 IX. RELATIONSHIP BETWEEN AGE AND THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING AND BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION 57 X. RELATIONSHIP BETWEEN TYPE OF INCISION AND THE SCORE ON PERFORMANCE ON DEEP BREATHING, COUGHING, AND BED EXERCISES IN INDIVI-DUAL AND GROUP INSTRUCTION 59 x xi Table Page XI. RELATIONSHIP BETWEEN ANALGESIC ADMINISTRATION AND THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING, AND BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION . . . 60 XII. RELATIONSHIP BETWEEN THE SELECTED CHARACTER-ISTICS AND THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS IN INDIVIDUAL AND GROUP INSTRUCTION 62 XIII. RELATIONSHIP BETWEEN AGE AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . . . . 64 XIV. RELATIONSHIP BETWEEN SEX AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . . . . 65 XV. RELATIONSHIP BETWEEN SMOKING HABITS AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION 66 XVI. RELATIONSHIP BETWEEN WEIGHT AND LENGTH OF HOSPITAL FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . . . . 67 XVII. RELATIONSHIP BETWEEN TYPE OF INCISION AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION 68 XVIII. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON DEEP BREATHING 125 XIX. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON COUGHING 126 XX COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON BED EXERCISES 127 XXI. RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF DEEP BREATHING IN INDIVIDUAL AND GROUP INSTRUCTION . . . . 128 xi i Table Page XXII. RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF COUGHING IN INDIVIDUAL AND GROUP INSTRUCTION . . . . 129 XXIII. RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION . . . . 130 XXIV RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF DEEP BREATHING IN INDIVIDUAL AND GROUP INSTRUCTION . 131 XXV. RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF COUGHING IN INDIVIDUAL AND GROUP INSTRUCTION . . . 132 XXVI. RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION . . . 133 XXVII. RELATIONSHIP BETWEEN AGE AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION 134 XXVIII. RELATIONSHIP BETWEEN SEX AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . * 135 XXIX. RELATIONSHIP BETWEEN SMOKING HABITS AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . 136 XXX. RELATIONSHIP BETWEEN WEIGHT AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION . . . . 137 XXXI. RELATIONSHIP BETWEEN TYPE OF INCISION AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION 138 XXXII. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY TYPE OF SURGERY AND BY SEX 139 xi i i Table Page XXXIII CANADIAN AVERAGE WEIGHTS FOR HEIGHT AND AGE - WOMEN 141 XXXIV CANADIAN AVERAGE WEIGHTS FOR HEIGHT AND AGE - MEN 141 CHAPTER I INTRODUCTION Postoperative pulmonary and circulatory complications remain a serious concern despite the recent advances in anesthesio-logy and surgical techniques.^ Pulmonary complications are one of the most common causes of prolonged hospital ization and increased 2 mortality after surgery. Preoperative instruction has been suggested in the l i terature as one possible means of preventing or minimizing post-3 4 operative complications. ' Studies have demonstrated that pre-operative instruction in deep breathing, coughing and bed exercises have been effective in promoting speedy recovery after surgery, by H. H. Bendixen and others, Respiratory Care, (Saint Louis: The C. V. Mosby Co., 1965), p. 85. 2 John F. Lewis and John H. Welch, "Respiratory Mechanics in Postoperative Patients," Surgery, Gynecology, and  Obstetrics, CXX (February, 1965), 305. 3 S. Ayers and S. Giannel l is , Care of the C r i t i c a l l y  111, (New York: Appleton-Century-Crofts, 1967), p. 126. 4 Bendixen and others, p. 89. - 1 -- 2 -5 6 preventing postoperative pulmonary and circulatory complications. * Group instruction has recently been promoted as a valuable teaching technique, with i ts main advantages stated as economy of time and the beneficial effect of the group interaction 7 on the individual. Group instruction has been found effective in many areas of nursing, yet preoperative instruction is usually given Q individually. The promotion of group preoperative instruction is one means of providing adequate instruction to surgical patients, as this method requires less time and personnel compared to i n d i v i -dual instruction. This study attempts to compare the effectiveness of two modes of preoperative instruction in deep breathing, coughing and bed exercises: individual and group instruction. J K. M. Healy, "Does Preoperative Instruction Make a Difference," American Journal of Nursing, LXVIII (January, 1968), 62-67. fi C. A. Lindeman and B. Van Aernam, "Nursing Intervention With the Presurgical Patient - The Effects of Structured and Unstructured Preoperative Teaching," Nursing Research, XX (July-August, 1971), 319-332. Barbara K. Redman, The Process of Patient Teaching  in Nursing, (Saint Louis: The C. V. Mosby Co., 1972), p. 93. Ib id . , p. 94. - 3 -THE PROBLEM Statement The major question asked in the study was: Is group preoperative instruction in deep breathing, coughing, and bed exercises as effective as individual instruction? The specif ic quesitions investigated were: 1. Is group preoperative instruction in deep breathing, coughing, and bed exercises as effective as individual instruct ion; as measured by the performance of exercises, the incidence of postoperative complications, and the length of hospital stay? 2. Is there a relationship between one or more of the selected characteristics of the subjects (age, sex, smoking habits, weight, and type of incision) and the effectiveness of individual and group instruction; as measured by the above variables. Significance The importance of preoperative instruct ion, to enhance postoperative recovery, has been reported by several authors. Bendixen and others, stated: Instruction and encouragement is part icular ly important before an operation: i f properly carried out this may not only improve the patient's morale but affect his physical well-being in the postoperative period, reduce the amount of narcotics needed, and shorten the length of s tay . 9 Bendixen and others, p. 89. - 4 -Studies have further demonstrated that effective pre-operative instruction in deep breathing, coughing, and bed exercises reduces the length of hospital stay for surgical patients, by en-hancing speedy recovery.^ 0 , 1 1 This is a s ignif icant contribution to the health care system given the present status of the national economy and the increasing costs of hospital care. The teaching of patients i s recognized as an integral 12 13 14 part of professional nursing practice. ' ' A cru ic ia l issue in patient education i s attainment of more ef f ic ient means of teaching, since professional services are costly. The necessity for maintaining or improving the quality of instruction, despite the increasing number of patients requiring health teaching,is a d i f f i c u l t y facing the nursing profession. Pohl identif ied the major obstacles to teaching 15 as lack of time, heavy workload, and under staf f ing. With the increasing demands on the nurse's time; group teaching may be 1 0 Healy, p. 62-67. ^ Lindeman and Van Aernam, p. 319-332. 12 Jeanne C. Hallburg, "Teaching Patients Self -Care," Nursing Cl inics of North America, V (June, 1970), 223. 13 Lois A. Monteiro, "Notes on Patient Teaching - A Neglected Area," Nursing Forum, III (Winter, 1964), 262. 1 4 Margaret L. Pohl, "Teaching Act iv i t ies of the Nursing Practit ioner," Nursing Research. XIV (Winter, 1965), 11. 1 5 Ibid. - 5 -necessary to meet the responsibi l i ty of adequate patient teaching. 1 Pi 17 It is obvious that teaching in groups saves time. ' Group instruction is not new to nursing. It has been widely used for prenatal classes, post-natal classes, baby bath demon-strations, and out-patient classes for diabetics. Despite the success of group instruction in these areas, the approach has not been widely implemented in hospitals. In fact much instruction given by nurses in the hospital setting is done on a one-to-one basis in situations 18 where the benefits of group instruction might be considered. Hospital nursing experience with surgical patients revealed to the investigator that preoperative teaching is one area where the group method can be used ef fect ive ly . Also, i t has been noted by the investigator that, when preoperative instruction was instituted indiv idual ly , many surgical patients were deprived of adequate instruction. Observation of individual preoperative instruction identif ied i t to be unstructured and inconsistent. It is usually 1 c Margaret L. Pohl, Teaching Function of the  Nursing Practit ioner, (Iowa: William C. Brown Co., 1973), p. 72. ^ Redman, The Process of Patient Teaching, p. 94. Barbara K. Redman, "Patient Education as a Function of Nursing Pract ice," Nursing Cl in ics of North America, VI (December, 1971), 579. - 6 -'h i t and miss' information given to a patient while carrying out a nursing technique. Lindeman and Van Aernam stated: Observation of preoperative teaching in various hospitals has shown that i t tends to re -semble ' t e l l i n g ' rather than 'teaching' and con-sists of general vague statements rather than specific ins t ruc t ions . ' 9 Nurses, however, have questioned the effectiveness of group preoperative instruction. They have implied that l istening to someone else's experience in a group would increase anxiety in patients. The above factors suggested the need to investigate the effectiveness of group instruction, assuming that any evidence of the effectiveness of group preoperative instruction would promote this approach within the hospital sett ing. Promotion of group instruction would ensure adequate preoperative instruction on a wider scale. Accordingly, the findings in this study may aid in improving the quality of one area of nursing intervention: the preoperative instruct ion. DESCRIPTION OF THE STUDY Specific Objectives The specif ic objectives of the study were to: 1. provide the subjects with knowledge and s k i l l s to perform deep breathing, coughing, and bed exercises as stated in the evaluation guide of performance; Lindeman and Van Aernam, "The Effects of Structured and Unstructured Preoperative Teaching," p. 320. - 7 -2. provide preoperative instruction individually to a l l the subjects in the individual instruction category; 3. provide preoperative instruction in small groups to a l l the subjects in the group instruction category; 4. compare the effectiveness of individual and group preoperative instruction as measured by the performance of exercises, the incidence of postoperative complications, and the length of hospital stay; and 5. determine the relationship between the selected characteristics of the subjects and the effectiveness of individual and group preoperative instruction as measured by the above variables. Hypotheses The following null hypotheses were tested in the study: Hypothesis I. There is no signif icant difference in the postoperative performance of deep breathing, coughing, and bed exercises by subjects receiving the individual instruction as compared with subjects receiving the group instruct ion. Hypothesis I I . There is no signif icant difference in the incidence of postoperative complications for subjects receiving the individual instruction as compared with subjects receiving the group instruction. - 8 -Hypothesis III . There is no signif icant difference in the length of hospital stay for subjects receiving the individual instruction as compared with subjects receiving the group instruction. Variables The independent variable was the method of pre-operative instruction. Two modes of instruction were included: 1. Individual instruction 2. Group instruction The dependent variables were: 1. The performance of exercises; 2. The incidence of postoperative complications; and 3. The length of hospital stay. The performance of exercises. The performance of deep breathing, coughing, and bed exercises was evaluated on the f i r s t postoperative day, by means of the evaluation guide of performance too l . This was selected as a dependent variable because i t measures the s k i l l s learned through individual and group instruction. Preoperative instruction in deep breathing, coughing, and bed exercises f a c i l i t a t e d the learning of these s k i l l s . Lindeman and Van Aernam demonstrated that, the a b i l i t y of subjects to deep breathe and cough postoperative-20 ly was s ignif icant ly improved by structured preoperative instruction. Lindeman and Van Aernam, "The Effects of Structured and Unstructured Preoperative Teaching," p. 319-332. - 9 -Berecek and Janson used performance of deep breathing and coughing as a dependent variable in their study, to evaluate the effect of three procedures for teaching deep breathing and coughing 21 exercises. They identif ied i t as a valid measure. The incidence of postoperative complications. The incidence of postoperative pulmonary and circulatory complications was selected as the second dependent variable. The l i terature ade-quately supports deep breathing, coughing, and bed exercises as necessary measures to minimize or prevent postoperative pulmonary and circulatory complications. Preoperative instruction is one means to ensure effective performance of these exercises during the post-operative period. Therefore, incidence of postoperative pulmonary and circulatory complications can be used as a variable to measure the effectiveness of individual and group preoperative instruct ion. Previous researchers have used this variable, to measure the effect ive-22 23 ness of preoperative instruct ion, and found i t va l id . ' 21 K. H. Berecek and S. L. Janson, "Influence of Postanesthetic Suggestion on Prevention of Postoperative Pulmonary Complications," CHEST, LXI (March, 1972), 240-46. 2 2 Ibid. 23 Healy, "Does Preoperative Instruction Make a Difference," p. 62-67. - 10 -Length of hospital stay. This third dependent variable was selected on the assumption that preoperative instruction promotes postoperative recovery and reduces length of hospital stay for surgi -cal patients. Hospital stay is increased by the incidence of post-operative complications. Researchers have used this variable in previous studies and found i t va l id . Healy found that preoperative instruction in deep breathing, coughing, and turning reduced length 24 of hospital stay for surgical patients. Lindeman and Van Aernam used length of hospital stay as a dependent variable to measure the effectiveness of structured preoperative instruction in deep 25 breathing, coughing, and bed exercises. The study revealed that the mean length of hospital stay was s ignif icant ly reduced by the implementation of structured instruction. Length of hospital stay was used as a dependent variable to compare the effectiveness of individual and group preoperative instruction in deep breathing, 26 coughing, and bed exercises. Group preoperative instruction was found to be as effective as individual instruction as measured by the length of hospital stay. Healy, "Does Preoperative Instruction Make a Difference?," p. 62-67. 25 Lindeman and Van Aernam, "The Effects of Structured and Unstructured Preoperative Teaching," p. 319-332. Lindeman, "Nursing Intervention with the Presurgi-cal Patient - Effectiveness and Efficiency of Group and Individual Preoperative Teaching," Nursing Research, XXI (May - June, 1972), 196-208. - n -The number of intervening factors, that influence the dependent variables of the study, are recognized by the invest i -gator. The incidence of postoperative complications and the length of hospital stay, being outcomes of patient care, are influenced by a number of factors and i t is necessary to control these factors 27 to ensure va l id i ty of the study. However, "outcomes, by and large, remain the ultimate validators of the effectiveness and quality of 28 medical care." The performance of exercises, by contrast, is a process of patient care, one of the many factors leading to a success-ful outcome, and a more direct measure of the effectiveness of instruction. Moreover, the study assumed that by randomly assigning the subjects to either individual or group preoperative instruct ion, the effect of the intervening variables would be equal in both the groups. Definition of Terms Preoperative instruction: refers to the instruction in and demonstration of, the purpose and technique of deep breathing, coughing, and bed exercises to adult surgical patients in small groups or indiv idual ly , with the help of a booklet devised for the study. The teaching sessions included time to practise the s k i l l s , 27 Avedis Donabedian, "Evaluating the Quality of Medical Care," The Milbank Memorial Fund Quarterly, XLIV, No. 3. Part 2 (July, 1966), 168. 2 8 I b id . , p. 169. - 12 -unti l each patient could successfully perform the deep breathing, cough-ing, and bed exercises. The time involved was thirty to forty minutes for each session. The preoperative instruction was given by the investigator and the preoperative teaching nurse. The preoperative teaching nurse: refers to the registered nurse who was oriented to the use of the booklet and the study, and who helped with the inst i tut ion of peroperative instruction. Individual instruction: refers to the preoperative instruction, to one adult surgical patient. Group instruction: refers to the preoperative instruct ion, to a group of four to twelve adult surgical patients. Adult surgical patient: refers to the patient, between the ages of sixteen and seventy-five years, who was admitted to one surgical f loor of a selected general hospita l . General elective surgery: refers to abdominal surgery which was elect ively posted on the operating room schedule. The performance of exercises: refers to the performance of deep breathing, coughing, and bed exercises by each subject on the f i r s t postoperative day, which was measured by the evaluation guide of performance. The incidence cf postoperative complications: refers to the number of subjects who developed postoperative pulmonary and c i r -culatory complications such as atelectasis,pneumonia,and thrombophlebitis, which are diagnosed and stated in patient's chart. - 13 -The length of hospital stay: refers to the number of days the patient was hospitalized for surgery, counting from the day of surgery to the day of discharge, inclusive of both days. Weight: refers to the weight category (over-weight, average-weight, under-weight) for each subject. This was calculated by using a table of average weight for Canadians. Four pounds was used as upper and lower limits for each category, as recommended by the 29 Metropolitan Life Insurance Table. The table for average weights is contained in Appendix D. Heavy-smoker: refers to any subject who smokes more than half a package of cigarettes a day. Light-smoker: refers to any subject who smokes less than half package of cigarettes per day or who smokes cigars or a pipe. Non-smoker: refers to any subject who does not smoke. Basic Assumptions This study was based on the following assumptions: 1. Patient teaching is an integral function of profes-sional nursing practice, and the evaluation of the effectiveness of existing teaching methods, is a necessity. Sue Rodwell Williams, Nutrition and Diet Therapy, (Saint Louis: The C. V. Mosby Company, 1969), p. 645, c i t ing "Metro-politan Life Insurance Table." - 14 -2. Preoperative instruction in deep breathing, coughing, and bed exercises is one means by which postoperative pulmonary and circulatory complications can be minimized or prevented. 3. Any evidence of the effectiveness of group pre-operative instruction may promote this approach within the hospital setting. 4. Promotion of group preoperative instruction is one possible means by which most surgical patients can be assured of adequate instruction. Limitations of the Study The study was subject to the following l imitat ions: 1. The study lacked a control group of subjects who did not receive any structured preoperative instruct ion, therefore comparision of individual and group instruction to no structured instruction was not possible. 2. The study was limited to one unit of a particular hospital , therefore the results may not be relevant to the general population. 3. The study was limited to sixty patients undergoing abdominal surgery, who met the selected c r i te r ia of the study, there-fore the results may not be applicable to surgical patients at large. 4. The dependent variables of the incidence of postoperative complications and the length of hospital stay, being - 15 -outcomes of patient care, were subject to a number of intervening variables. CHAPTER II A review of the l i terature indicated that there was abundant l i terature related to the topic of preoperative instruction. A few of the di rect ly related sources have been selected to provide a basis for this study. The l i terature review is discussed under the following major headings: individual instruction; group instruction; preopera-t ive instruction in general; and preoperative instruction in deep breathing, coughing, and bed exercises. INDIVIDUAL INSTRUCTION Individual instruction is based on the belief in the uniqueness of each person. It takes into account individual d i f -ferences J Individual instruction requires the teacher to encourage individual interests, allow for individual sty les, and respond to 2 individual needs. In health teaching, certain patients, especially the older patients, have very individualized teaching requirements. ^ George Thomas and Joseph Crescimberni, Individualiz- ing Instruction in the Elementary School, (New York: Random House, 1967), p. 3. 2 Bernice J . Wolfson, "Individualizing Instruction," Individualization of Instruction - A Teaching Strategy, ed . , V.M. Howes, (London: The Macmillan Co. , 1970), p. 101. - 16 -because of their unique problems.0 These unique problems and i n -dividual differences emphasize the need for planned and informal individual instruction. Individual instruction has been instituted in d i f -ferent ways by nurse practit ioners, Pohl interprets i t mainly as informal, incidental , casual, and mostly 'on-the-spot' teaching.^ Monteiro describes i t as the, "unplanned incidental teaching in 5 quasi-spontaneous response to a patient's statement or question." Redman sees i t mainly as helping patients to cope with a health stress in an unstructured way and in an informal atmosphere. A large part of the nurse's teaching can be done at the bedside while admini-stering nursing care. Planning the teaching objectives in advance of giving care wi l l contribute to the effectiveness of individual instruction.^ ° Barbara K. Redman, The Process of Patient  Teaching in Nursing, (Saint Louis: The C. V. Mosby Co., 1972), p. 54. 4 Margaret L. Pohl, Teaching Function of the Nursing  Practit ioner, (2nd ed . , Iowa: William C. Brown Co., 1973), p. 70. 5 Lois A. Monteiro, "Notes on Patient Teaching - A Neglected Area," Nursing Forum, III (Winter, 1964), 26. 6 Redman, p. 92. ^ Margaret L. Pohl, "Teaching Act iv i t ies of the Nursing Practit ioner," Nursing Research, XIV. (Winter, 1965), 11. - 18 -Informal individual instruction is considered an essential part of health teaching as i t is based on the patient's interests and immediate needs. Palm stated: Formal or group teaching method cannot in anyway meet the learning needs of each and every patient. Patient's learning needs cannot always be anticipated, nor can the patient's need for teach-ing necessarily be postponed unti l there is time and preparation by the nurse for a formal teaching situation.8 This unstructured and incidental teaching is dependent upon the nurse's pr ior i ty to the teaching function in that particular 9 situation. Individual instruction has also been given as planned, structured and formal, by nurse practit ioners. Pohl recommends that structured individual instruction be a nursing function, best per-formed by a nurse practit ionerJ° The effectiveness of structured and planned individual instruction has been investigated by nurse researchers. Goodman evaluated the effectiveness of planned instruction on the self-medication practices of ambulatory cardiac patients. She taught twenty patients individually in the experimental o Mary Lock Palm, "Recognizing Opportunities for Informal Patient Teachings," Nursing Cl inics of North America, VI (December, 1971), 670. 9 Ib id . , p. 671* ^ Pohl, "Teaching Act iv i t ies of the Nursing Practit ioner," p. 11. - 19 -group. Her study revealed that the patients in the experimental group made signif icant ly fewer errors as compared with the twenty control group patients, who did not receive the planned teaching.^ This study substantiated the effectiveness of planned individual instruction for cardiac patients. Effectiveness of a 'Diabetic Teaching Tool' was tested after instructing twenty diabetic patients individually . The knowledge and s k i l l s of these twenty patients in the experi-mental group were compared with those of twenty patients in the control group who did not receive the planned and structured teaching, using the tool.. The results of the study showed that the patients in the experimental group scored s igni f icant ly 12 higher points. The effectiveness of structured individual instruc-tion for diabetic patients was demonstrated by this study. Power did an experimental study to investigate the effectiveness of planned instruction. She gave planned individual instruction to ten mothers of children who were admitted to the emergency department of a hospital , for cast application to fractured Gertrude W. Goodman, "An Experimental Study to Evaluate the Effect of Planned Teaching on Self-Medication Practices of Older Ambulatory Cardiac Patients," (unpublished Master's thesis , University of Br i t i sh Columbia, 1972). 12 Judith M. Skelton, "An Experimental Study to Evaluate the Effectiveness of a Diabetic Teaching Tool," (unpublished Master's thesis, University of Br i t i sh Columbia, 1973). - 20 -limbs. The a b i l i t i e s to cope with the home care of the chi ld on the part of the mothers who received planned instruction were compared with the coping a b i l i t i e s of mothers in the control group who did not receive any planned and structured teaching. Analysis of the data using the Mann-Whitney U test led to the rejection of the null hypothesis with p = .001, thus indicating a greater 13 ab i l i t y to cope by the mothers receiving the planned teaching. This study demonstrated the effectiveness of planned individual instruction given in the emergency department. GROUP INSTRUCTION Recent l i terature promotes group instruction as a necessity, not only in the health care system but also in the public educational system. The public school system promotes group instruction for the following reasons: 1. When a number of children have a common meaningful experience they want to discuss and think together. 2. Groups help themselves to attain needed s k i l l s not 14 developed in other ways. Denise Mary Power, "The Effectiveness of Planned Teaching of Mothers With Children Treated in Emergency Departments," (Unpublished Master's thesis, University of Br i t ish Columbia, 1972). 14 Doris M. Lee, "Do We Group in an Individualized Program?," Individualization of Instruction - A Teaching Strategy, p. 197. - 21 -Olmstead presented the following concepts as basic to the promotion of group instruction: 1. Social interaction is fundamental to a l l small group methods, and learning occurs through interaction between people, 2. Small group methods provide a supportive emotional climate that reduces resistance to learning. 3. The group provides a stimulus environment within 15 which learning is both stimulated and tested. Group instruction for patient teaching has been advocated for i ts many advantages. It is an economical way to teach a number of individuals at one time, and small discussion groups are most useful in meeting objectives regarding attitudes 16 17 or part ia l ly developed concepts. ' Members of the group benefit from sharing experiences and exchanging ideas about their problems. Some group members, for example, may find i t helpful to know that their problems are not unique. The question asked by one in a group 18 may be of interest to others. 15 Joseph A. Olmstead, Theory and State of the Art  of Small Group Methods of Instruction, (Georgia: HUM RRO Division No. 4, March, 1970), p. 8-15. p. 75. p. 93. p. 74-75. ^ 6 Pohl, Teaching Function of the Nursing Practit ioner, ^ Redman, The Process of Patient Teaching in Nursing, 18 Pohl, Teaching Function of the Nursing Pract it ioner, - 22 -In the health care system, group instruction is exten-sively used in the areas of prenatal care, postpartum and infant care, 19 chi ld care, management of diabetes, as well as other types of care. A number of studies have investigated the effectiveness of group instruction in these areas. Two of the most relevant ones are cited for the purpose of this study. Haar described a study which revealed economy of time and special effects on motivation as the outcome of the group method of instruction. She conducted a program in which a group of teen-age-mothers of children with phenylketonuria, attended group sessions. She matched these mothers with a control group who received individual instruction from the public health nurse at home. The results of the study showed that six of the experimental group mothers gained optimum dietary control , whereas only one control group mother gained optimum dietary control . This was identif ied as signif icant at .05 20 leve l . However in her study, the setting for the two methods of teaching, was not controlled. Since the group method of instruction was given by the investigator, and the individual instruction by a public health nurse, there may have been a bias in the teaching which was not taken into account. I y Redman, The Process of Patient Teaching in Nursing. p. 94. on Doris J . Haar, "Improved Phenylketonuric Diet Control Through Group Education of Mothers," Nursing Cl inics of  North America, I (December, 1966), 715-723. » - 23 -The relative effectiveness of group and individual diabetic instruction was investigated by Nickerson. The hypothesis tested in this study was: hospital patients with diabetes mellitus would demonstrate as much, or more, knowledge of diabetes, and s k i l l in urine testing after group instruction by a nurse special ist in diabetes, as after individual instruction. Of the forty-one patients who participated in the study, f i f teen received group instruct ion, f i fteen received individual instruct ion, and eleven were control subjects. The results of the study indicated that the control group showed almost no progress; the average increase in score for i n d i v i -dually taught patients was 12.4 points, while for the group method 21 the mean score was 16.5 points. This study demonstrated that group instruction was more effective than individual instruction for d ia -betic patients. Diabetic," Donna Nickerson, "Teaching American Journal of Nursing, LXXII the Hospitalized (May, 1972), 935-939. - 24 -PREOPERATIVE INSTRUCTION IN GENERAL The need for preoperative instruction has been stated consistently in the l i terature . Studies have been done to substanti-ate this need in various aspects of surgical patient care. Even though the group method of instruction is extensively used in many areas of patient care, the most common approach to preoperative 22 instruction is s t i l l the individual method. The effectiveness of preoperative instruction upon postoperative patient behaviour, has been investigated by several researchers. An experimental study, reported by Egbert, determined the effectiveness of preoperative instruction, suggestion, and en-couragement in reducing the severity of postoperative pain. The study revealed that subjects, in the experimental group, who received information and reassurance regarding postoperative pain required fewer narcotics and had reduced length of hospital stay, as compared with the control subjects who did not receive any preoperative 23 instruction. This study substantiated the need for preoperative 23 instruction in one particular aspect. 22 Redman, The Process of Patient Teaching in Nursing, p. 94. 23 L. Egbert and others, "Reduction of Postopera-tive Pain by Encouragement and Instruction of Patients," New England  Journal of Medicine, CCLXX, No. 16 (April 16, 1964), 825-827. - 25 -The study done by Mezzanotte has been identif ied as the f i r s t to attempt the group method, in the instruction of pre-operative patients. She instructed twenty-four surgical patients in groups of four. They were interviewed postoperatively to evaluate the effectiveness of the instruction. Interview results stated that twenty of the twenty-four patients preferred the group method of 24 instruction. Her study, though limited to permit definite con-clusions, supports group technique as an effective method for pre-operative instruction. Schmitt and Wooldridge used small group discussion method in which the patients expressed their concerns and fears; and received information about what to expect and how to aid in their own 25 recuperation. The study indicated that the twenty-five patients who participated in group session slept better the night before surgery, experienced less anxiety on the morning of surgery and recalled more facts about their experiences on the day of surgery. The patients in the experimental group were discharged sooner as compared with the twenty-five control patients who did not p a r t i c i -pate in the group discussion. The results of this study demonstrated 24 Elizabeth J . Mezzanotte, "Group Instruction in Preparation for Surgery," American Journal of Nursing, LXX (January, 1970), 89-91. 25 Florence E. Schmitt and Powhatan J . Wooldridge, "Psychological Preparation of Surgical Patients," Nursing Research, XXII. (March - A p r i l , 1973), 108-115. - 26 -that group preoperative conference, in which the patients were allowed to express their fears and concerns in addition to instruction in postoperative nursing measures, promoted postoperative recovery. PREOPERATIVE INSTRUCTION IN DEEP BREATHING, COUGHING, AND BED EXERCISES Importance of Instruction in Deep Breathing, Coughing, and Bed Exercises Instruction in deep breathing, coughing, and bed exercises has been identif ied as important information for surgical patients. WeiIer interviewed one hundred patients who had open heart surgery, on their seventh or eighth postoperative day. They rated explanation about deep breathing, coughing, and the intensive 26 care unit as the most valuable information. Preoperative instruction in deep breathing, coughing, and bed exercises has been stated as an effective nursing measure in preventing or minimizing postoperative pulmonary and circulatory 27 complications. Postoperative complications. Pulmonary and circulatory complications remain a serious concern after surgery. Postoperative pulmonary complications are the largest single cause of morbidity, Sister M. Cashel Weiler, "Postoperative Patients Evaluate Preoperative Instruction," American Journal of Nursing, LXVIII (July, 1968), 1465-67. 71 H. H. Bendixen and Others, Respiratory Care, (Saint Louis: The C. V. Mosby Co., 1965), p. 89. - 27 -28 29 30 prolonged hospitalization and mortality among surgical patients. ' ' Wightman conducted a study which indicated a high incidence of post-31 operative pulmonary complications. He identif ied forty-nme post-operative pulmonary complications in the total of 785 patients, who had surgery under general anesthesia. Atelectasis and pneumonia are identif ied as the most 32 33 common pulmonary complications, ' and thrombophlebitis as the 34 most common circulatory complication. Atelectasis is estimated to account for more than 90 percent of postoperative pulmonary complications. 35 28 Bendixen and others, Respiratory Care, p. 85. 29 Lois T. E l l ison and others, "Oxygen Requirements in the Early Postoperative Period (48 hours): Ventilation and Res-piratory Exchange," Annals of Surgery, CLXIII (Apr i l , 1966), 559. 30 John F. Lewis and John H. Welch, "Respiratory Mechanics in Postoperative Patients," Surgery, Gynecology, and  Obstetrics, CXX (February, 1965), 305. 31 J . A. K. Wightman, "A Prospective Survey of the Incidence of Postoperative Pulmonary Complications," Br i t ish Journal  of Surgery, LV, (February, 1968), 85-91. 32 W. H. Anderson, B. E. Dorsett, and G. L. Hamilton, "Prevention of Postoperative Pulmonary Complications," Journal of  American Medical Association, CLXXXVI (November 23, 1963), 763. 3 3 A. R. Anscombe and Rogert St. J . Buxton, "Effects of Abdominal Operations in Total Lung Capacity and Its Subdivisions," Br i t ish Medical Journal, II. (July 12, 1958), 84» 3 ^ K. N. Shafer and Others, Medical Surgical Nursing, (5th ed . ; Saint Louis: The C. V. Mosby Co., 1971), p. 185. 35 W. K. Hamilton, "Atelectasis, Pneumothorax, and Aspiration as Postoperative Complications," Anesthesiology, XXV (September - October, 1961), 708. - 28 -The incidence of postoperative complications were studied in 1,240 patients, who had abdominal surgery, by Dripps and 36 Deming. Their study involved establishing a prophylactic regimen consisting of hourly turning, encouraging cough with support of the abdominal wa l l , suction as necessary, and minimal use of analgesics. The incidence of postoperative complications decreased from eleven percent in 250 cases before inst i tut ing the prophylactic regimen to 4.1 percent in nine hundred cases after the prophylactic regimen. This study demonstrated that turning and coughing measures after surgery, reduced the incidence of postoperative atelectasis and pneumonia. Factors influencing complications. A number of factors influence the incidence of postoperative complications. Bendixen reported; age, sex, obesity, smoking, pre-existing pulmonary diseases, pain and the use of pain rel ieving drugs, abdominal distention, and 37 general anesthesia as signif icant influencing factors. Egbert identif ied the type of incision as an influencing factor as certain 38 types tended to inhibit coughing during the postoperative period. R. D. Dripps and M. V. Deming, "Postoperative Atelectasis and Pneumonia: Diagnosis, Etiology, and Management Based on 1,240 Cases of Upper Abdominal Surgery," Annals of Surgery, CXXIV. (July, 1946), 94-110. 3 7 Bendixen and Others, Respiratory Care, p. 28-40. 3 8 L. D. Egbert and Others, "Effect of Site of Operation and Type of Anesthesia Upon the Ab i l i t y of Cough in the Postoperative Period," Surgery, Gynecology, and Obstetrics, CXV (September, 1962), 298. - 29 -Effective Performance of Deep Breathing, Coughing, and Bed Exercises Several characteristics contribute to the effective performance of deep breathing, coughing, and bed exercises. Deep breathing. It helps prevent aveolar collapse and di late airways, thus minimizing the incidence of ateletasis . For effective deep breathing each inspiration and expiration should 39 be carried out slowly and deliberately. A deep breath which is held for three seconds was found more effective than merely taking a 40 deep breath or multiple deep breaths. Lower chest expansion should be encouraged during deep breathing exercise because the lower 41 lung lobes are most susceptible to atelectasis and pneumonia. Coughing. It assists in removing retained secretions. Coughing is recommended as a prophylactic and therapeutic measure for atelectasis and pneumonia. Postoperative atelectasis and pneumonia are thought to be result of ineffective coughing resulting in 42 secretions which obstruct the airway. Supporting the incision by manual pressure and the effective use of analgesics to relieve pain, 39 Bendixen and Others, Respiratory Care, p. 94. 40 R. J . Ward and Others, "An Evaluation of Post-operative Respiratory Maneuvers," Surgery, Gynecology, and Obstetrics, CXXIII (July, 1966), 53. 41 H. H. Bendixen, J . Hedley-White, and M. B. Laver, "Impaired Oxygenation in Surgical Patients During General Anesthesia with Controlled Ventilation (A Concept of Atelectasis) , " New England  Journal of Medicine, CCLXIX (November 7, 1963), 994. ^ Egbert and Others, p. 295. - 30 -43 make coughing less painful? A deep cough originating from the lower part of the chest, and sputum production are character ist ics 44 of a successful cough. Bed exercises. It includes leg and foot exercises and turning measures. Immobilization contributes to postoperative pulmonary and circulatory complications. Bed exercises minimize the " effect of venous stasis and promote c i r cu la t ion , par t icu lar ly in the 45 lower extremities. Turning from supine to lateral positions a l ternate ly , decreases congestion in the lungs and encourages drainage of secret-ions. Thus turning promotes chest expansion result ing in better , . , , . 46 vent i lat ion . Effectiveness of Preoperative Instruction in Deep Breathing, Coughing, and Bed Exercises A review of the l i terature ident i f ied three studies investigating the effectiveness of preoperative instruct ion in deep breathing, coughing, and bed exercises. 43 Bendixen and Others, Respiratory Care, p. 94. 44 Jane Secor, Patient Care in Respiratory Problems, (Philadelphia: W. B. Saunders Company, 1966), p. 88. 45 R. D. Dripps and R. M. Waters, "Nursing Care of Surgical Patients I - The ' S t i r - U p ' , " American Journal of Nursing, XLI (May, 1941), 531. 4 6 Shafer and Others, Medical Surgical Nursing, p. 84. - 31 -Healy conducted a study in which 181 surgical patients received individual instruction in deep breathing, coughing, and turning. They were compared with 140 control patients who did not receive any specif ic planned instruction. Results of the study showed that 135 patients in the experimental group went home three to four days ear l ier than their expected day of discharge, whereas only three control patients were discharged prior to the expected date. The experimental group had only three postoperative complicat-47 ions as compared to sixteen complications in the control group. Healy identif ied the value of having a definite time set aside for preoperative instruct ion. Her study demonstrated the effectiveness of structured and planned preoperative instruction. A similar study using an experimental design was conducted by Lindeman and Van Aernam, in which 126 adult surgical patients were given structured preoperative instruction in deep breathing, coughing and bed exercises. Postoperative ventilatory function, length of hospital stay, and postoperative need for analgesics were used as dependent variables to test the effectiveness of the structured preoperative instruction. The results were compared with those of 135 control subjects who did not receive such structured instruction. The data, analysed at a .05 significance l e v e l , showed the following results : . Katherine M. Healy, "Does Preoperative Instruction Make a Difference?," American Journal of Nursing, LXVIII (January, 1968), 62-67. - 32 -1. The ab i l i t y of subjects to deep breathe and cough postoperatively was s ignif icant ly improved by the structured teaching method-2. The mean length of hospital stay was s igni f icant ly reduced by the implementation of structured instruction-3. There was no di f ferent ia l effect upon postoperative need for analgesia.^ 8 Preoperative instruction in deep breathing, coughing, and bed exercises has been used by Lindeman to compare the effects of group and individual methods of instruction. In this study structured preoperative instruction was implemented with the help of a sound-on-slide program, by thirty-one registered nurses. Subjects in this study were randomly assigned to group or individual method of instruction. The dependent variables used in this study were postoperative ventilatory function, length of hospital stay, post-operative need for analgesia, and length of learning time. This study concluded that group preoperative instruction was found to be 49 as effective as and more ef f ic ient than individual instruction. ' t u C. A. Lindeman and B. Van Aernam, "Nursing Inter-vention with the Presurgical Patient - The Effects of Structured and Unstructured Preoperative Teaching," Nursing Research, XX (July -August, 1971), 319-332. ^ 9 C. A. Lindeman, "Nursing Intervention with the Presurgical Patient - Effectiveness and Efficiency of Group and Individual Preoperative Teaching," Nursing Research, XXI (May - June, 1972), 196-208. . - 33 -The present study differs from Lindeman's study in that only those subjects undergoing abdominal surgery have been i n -cluded. Consistency in teaching was ensured by having the invest i -gator and one other nurse inst i tut ing structured instruction by means of a booklet. The effectiveness of preoperative instruction was measured by the postoperative performance of exercises, the incidence of postoperative complications and the length of hospital stay. SUMMARY Pulmonary and circulatory complications, after major surgery, remain a serious medical concern. Deep breathing, coughing, and bed exercise measures, during the postoperative period prevent or minimize pulmonary and circulatory complications, promote speedy recovery and thus, reduce the length of hospital stay. The review in the preceding paper has stressed the need for preoperative instruction to promote postoperative recovery. The effectiveness of structured and planned instruction has been a primary concern of the studies on preoperative instruction. Economy of time and the beneficial effect of the group on the individual have been stated as the advantages of group instruct ion. The effect -iveness of group instruct ion, in many areas of patient care, has been demonstrated. However, preoperative instruction is usually given individual ly . Evidence of the effectiveness of group preoperative instruction is deemed necessary to promote this approach within the hospital sett ing. CHAPTER III METHODOLOGY The purpose of this study was to compare the effectiveness of individual and group preoperative instruction. Of the sixty subjects included in the study, th i r ty subjects received instruction in deep breathing, coughing, and bed exercises in small groups and thi r ty subjects received instruction individual ly . The effectiveness of the instruction was measured by the performance of exercises, the incidence of postoperative complications, and the length of hospital stay. This chapter w i l l focus on the three major steps, followed in the study: the development of the tools ; the selection of the setting and the subjects; and the data col lect ion procedure. DEVELOPMENT OF THE TOOLS The tools employed in the study were: the preoperative instruction tools , and the data col lection tools. The Preoperative Instruction Tools The tools for preoperative instruction included a booklet and a practice guide. The booklet. A booklet consisting of instruction in deep breathing, coughing, and bed exercises was developed to ensure - 34 -- 35 -consistency in teaching between the individual and the group instruction, between the researcher and the nurse who instituted the instruction, and the instruction from day to day. The booklet consisted of a compact easel binder, with coloured photographs accompanied by letraset and typed instructions. The booket was devised in such a way that the typed instructions on the one page pertains to the photograph on the opposite page. It was devised for use in individual instruction as well as instruction in small groups. The content of the booklet dealt with specif ic ins -tructions in deep breathing, coughing, and bed exercises for the surgical patient. The content was selected after consulting with a number of experts in the preoperative instruction of deep breathing, coughing, and bed exercises. The number of personal interviews held for consultation of content selection and development of the booklet, is included in the bibliography. The l i terature cited also provided a basis for content selection. The content was written in simple language with a minimum number of medical terms. A copy of the content of the booklet is contained in Appendix A. The practice guide. Each subject was given a practice guide, consisting of the information necessary to practice deep breathing, coughing, and bed exercises. It consisted of a brief summary of deep breathing, coughing, and bed exercises as outlined in the booklet. A copy of the practice guide is included in Appendix A, entitled "The Practice Guide for Deep Breathing, Coughing, and Bed - 36 -Exercises." The Data Collection Tools The tools for the col lect ion of data included a patient profi le sheet and an evaluation guide of performance. The patient prof i le sheet. This tool was devised to obtain pertinent data related to the selected characteristics of the subjects. The characteristics of age, sex, smoking habits, weight, and type of incision were selected for the purpose of the present study. Previous researchers have substantiated that these charac-te r is t i cs are related to the postoperative recovery. Bendixen and others, reported that age, sex, smoking, and obesity influence post-operative recovery.^ Egbert identif ied the type of incision as an influencing factor in coughing, during the postoperative period. The tool also included provision for entry of data on the incidence of postoperative complications and the length of hospital stay. A copy of this tool is contained in Appendix B. H. H. Bendixen and others, Respiratory Care (Saint Louis: the C.V. Mosby Company, 1965), p. 28-40. 2 L. D. Egbert and others, "Effect of Site of Operation and Type of Anesthesia upon the Ab i l i t y to Cough in the Postoperative Period," Surgery, Gynecology, and Obstetrics, CXV (September, 1962), 298. - 37 -The evaluation guide of performance. The purpose of this tool was to measure the performance of deep breathing, coughing, and bed exercises of each patient, in order to make an inference about the learning. Pain was recognized as an intervening variable in performing the exercises during the postoperative period. The time of the last analgesic administration before the evaluation of performance was recorded in the evaluation guide of performance tool. This was done to determine the relationship between pain and the performance of the exercises. The content of the tool consisted of steps in performing deep breathing, coughing, and bed exercises as stated in the instruc-tion booklet. Each step or item was a directly observable behavior, which were rated as one point. There was fourteen items in deep breathing, six items in coughing, and six items in bed exercises. The maximum score of twenty-six points was obtained by performing all the items, as listed in the evaluation guide. A copy of this tool is included in Appendix Bv Reliability and Validity of the Tools A measure is reliable i f i t is consistently repro-3 ducible. Validity answers the question: Does the instrument really 4 measure what it is supposed to measure? In order to ensure 3 Eugene Levine, "Experimental Design in Nursing Research," Nursing Research, IX (Fall, 1960), 208. 4 Ibid. - 38 -r e l i a b i l i t y and val id i ty of the tools , the following were the steps taken:' 1. The tools were submitted to a panel of experts and the thesis committee for examination, review, and revision of wording, relevance, and precision of content. The panel of experts consisted of four members who have expertise in the preoperative ins -truction of deep breathing, coughing, and bed exercises. The tools were then revised to include suggested changes. 2. The tools were tr ied out by the investigator and the staff participants of the study for relevance, precision, and r e l i a b i l i t y . A number of necessary changes became obvious. A major revision was made by deleting the evaluation of 'turning' from the evaluation guide of performance too l . Turning was found d i f f i c u l t to evaluate objectively, on the f i r s t postoperative day, as most patients needed some assistance in turning. Minor changes were made in the booklet and the patient prof i le sheet. 3. A p i lot study was conducted on a sample of four subjects, in which two subjects received individual instruction and two received group instruction. The revised tools were tested during the p i lot study. The va l id i ty of the evaluation guide of performance tool was established by testing the subjects before and after they received the instruction. The scores obtained after the instruction were s ignif icant ly higher for a l l the four subjects. This ensures - 39 -val id i ty of the evaluation guide of performance too l . The subjects included in the p i lot study scored maximum points on evaluation of performance after they received the instruction preoperatively. Thus i t was decided to eliminate preoperative evaluation from the study, assuming that the subjects would be able to do deep breathing, coughing, and bed exercises as stated in the evaluation guide, at the end of the practice session. In order to establish r e l i a b i l i t y of the evaluation guide of performance too l , the investigator and the physiotherapist evaluated the subjects on the f i r s t postoperative day. On readminis-tering the tool almost identical scores were obtained, which ensured r e l i a b i l i t y of the tool . THE SETTING AND THE SAMPLE The Setting The study was conducted on one surgical f loor of a two hundred and f i f t y six bed general hospital . Both male and female adult patients were admitted to this f loor for general surgery. One nurse was spec i f ica l ly assigned to admission of preoperative patients and inst i tut ion of preoperative instruction. The physiotherapist, who was assigned to the f loor , also assisted the patients with deep breathing, coughing, and bed exercise measures. Permission to conduct the study in the hospital was obtained from the director of nursing services of the hospital. - 40 -The Subjects Subjects, who met the following c r i t e r i a , were selected for the study: 1. between sixteen and seventy-five years of age; 2. admitted for elective abdominal surgery under general anesthesia; 3. free of existing systemic diseases including pulmonary and cardiac conditions; 4. not on preoperative intermittent positive pressure breathing therapy; 5. able to speak and read English; and 6. able to attend the preoperative teaching conference. The subjects were alternately assigned by week to either individual or group instruction. Of the sixty subjects in the study th i r ty received individual instruction and th i r ty received group instruction. The staff were not aware of the method of instruc-tion received by the subjects. This eliminated possible bias that may have occured in the pre- and post-operative care given to the subjects. THE PROCEDURE The major steps included in the procedure of the study were: staff orientation, the inst i tut ion of preoperative instruction, and the col lection of data. - 41 -Staff Orientation The purpose of the study was discussed and the tools were introduced to the staff participants. They included the pre-operative teaching nurse who assisted with the teaching and the physio-therapist who evaluated the performance of exercises. The preoperative teaching nurse was speci f ica l ly oriented to the use of the booklet in both individual and group instruction. The purpose of the study was discussed with the two head nurses, which helped to establish an effec-tive interpersonal relationship among the nurses on the f loor . Perio-dical meetings with the staff participants maintained a cooperative relationship during the study. The nursing staff and the physio-therapists were asked not to give any additional preoperative instruc-tion in deep breathing, coughing, and bed exercises to the subjects included in the study. Institution of Preoperative Instruction Individual and group preoperative instruction was alternated by week. The subjects were assigned to either individual or group instruction. Both individual and group instruction were given either by the investigator or by the preoperative teaching nurse, thus eliminating any possible bias that may have occured by one person teaching only one method of instruction. The preoperative instruction booklet was used in a l l the teaching sessions, in order to provide consistency in teaching. i - 42 -Preoperative instruction was given the day before surgery at a time between 15:00 and 18:00 hours. Subjects undergoing abdominal surgery, as l i s ted in the operating room schedule, were approached by the investigator or by the teaching nurse. Information regarding the selected characteristics in the study was obtained during this time from the chart and from the subject. Preoperative instruction was held in the conference room. Occasionally the individual instruction had to be held at the patient's bedside when the conference room was occupied. Each instruc-tion lasted thir ty to for ty - f ive minutes including the practice session. Group discussion was encouraged in group instruction. A semicircular seating arrangement was used in the group method, so that the booklet instruction was v is ib le to everyone in the group. Subjects other than those meeting the selected c r i t e r i a in the study were included in the group instruction, in order to maintain an effective group s ize . The individual and group instruction included practice sessions in which the subjects practised each exercise. The objective of the practice session was to make sure that the subjects learned to do deep breathing, coughing, and bed exercises as stated in the evaluation guide of performance tool . The time for practice session was not to exceed f i f teen minutes for both individual and group ins -truction. The subjects were also encouraged to practice the exercises during the preoperative period. Each subject was given a copy of the practice guide. - 43 -Collection of Data Data for the two dependent variables: the incidence of postoperative complications and the length of hospital stay, were collected by the investigator. The performance of exercises was eva-luated by the physiotherapist who was speci f ica l ly assigned to the f loor where the study was conducted. The performance of deep breathing, coughing, and bed exercises was evaluated on the f i r s t postoperative day before the physiotherapists began their postoperative regimen with the patient. This eliminated the poss ib i l i ty of any additional teaching by the physiotherapists. The instructions stated in the evaluation guide of performance tool assisted the physiotherapist in evaluating the performance of exercises. The time of evaluation was entered in the evaluation guide, which enabled the investigator to obtain the time of analgesic administration before the performance of exercises. The length of hospital stay for each subject was obtained by counting the number of days from the day of surgery to the day of discharge, including both days. The date of surgery and the date of discharge were obtained from the patient's chart. Subjects who stayed in the hospital after surgery, for reasons not related to the surgery, were excluded from the study. Thus two subjects were excluded; one subject who had a cholecystectomy underwent investigation for hypothyroidism; and another subject who had an inguinal hernia repair, was posted for transurethral prostatic resection. - 44 -Data on the incidence of postoperative complications were obtained from the chart as stated by the surgeon or as indicated by chest X-ray reports. Only diagnosed complications were included in the study. The col lection of data was discontinued after obtain-ing sixty subjects for the study. METHOD OF DATA ANALYSIS Analysis of the data included both descriptive analysis and s ta t i s t i ca l tests. Subjects receiving individual and group ins-truction were compared on selected characterist ics. Data in relation to hypotheses I and III were subjected to t tes tana lys is . Data in relation to hypothesis II were subjected to a chi-square test of significance using a 2 x 2 contingency table. The relationship between the selected characteristics of the subjects and the effect ive-ness of individual and group instruction was determined by means of a number of s ta t i s t i ca l tests. The .05 level of significance was accepted as s t a t i s t i c a l l y s ignif icant . SUMMARY This chapter focussed on the methodology of the study including a discussion of the development of the tools , the setting and the subjects, the inst i tut ion of preoperative instruction, the data col lection procedure and the method of data analysis. i CHAPTER IV ANALYSIS OF THE DATA The data were analysed and presented in this chapter in three sections. The first section is a comparison of subjects receiving individual and group instruction on the selected charac-teristics of the subjects. The second section contains analysis of the data in relation to the hypotheses of the study. The third section is devoted to examining the relationship between the selected charac-teristics and the effectiveness of individual and group instruction as measured by the postoperative performance of exercises, the incidence of complications, and the length of hospital stay. The tables of raw data used for the statistical analysis are contained in Appendix C. COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION TO THE SELECTED CHARACTERISTICS Data on age, sex, smoking habits, weight, and type of incision were tabulated. Subjects receiving individual instruction were compared with subjects receiving group instruction on these selected characteristics. A high similarity was obtained between two groups of subjects with respect of the selected characteristics. - 45 -- 46 -Age Comparison of subjects receiving individual and group instruction by age d ist r ibut ion, is shown in Table I. The median age for subjects receiving individual instruction was 47 years and for group instruction i t was 41 years. The mean age for individual ins -truction was 47.87 years and for group instruction i t was 44.37 years. Thus the subjects in individual and group instruction were similar in relation to age. TABLE I COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY AGE Age Individual Group (Years) instruction instruction 16-35 9 9 36-55 11 12 56-75 10_ 9 T o t a l 30 30 - 47 -Sex Comparison of subjects receiving individual and group instruction according to sex is shown in Table II. The subjects were s imi lar , in both groups, according to sex. In individual and group instruction there were more males than females (s ixty -s ix percent of males in individual instruction category, and f i f ty - three percent in group instruction category). TABLE II COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SEX Sex Individual Group instruction instruction Male 20 16 Female 10 14 T o t a l 30 30 Smoking Habits Table III shows the comparative distr ibution of the subjects by smoking habits. Light smokers were a small proportion of both groups, (6.6 percent in individual instruction and 10 per-cent in group instruction). In individual instruction there were 40 - 48 -percent non-smokers and 53.4 percent heavy smokers, whereas in group instruction there were 46.6 percent non-smokers and 43.4 percent heavy smokers. Thus the subjects in both groups were similar in relation to smoking habits. TABLE III COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SMOKING HABITS Smoking Individual Group habits instruction instruction Non-smoker 12 14 Light-smoker 2 3 Heavy-smoker 16 13 T o t a l 30 30 Weight The two groups were quite similar in weight as indicated in Table IV. Subjects with average weight formed the smaller group in both individual and group instruction (16 percent in individual instruc-tion and 20 percent in group instruction). In individual instruction 33.3 percent of subjects were over weight and 50.7 percent were under weight. In group instruction, there were 40 percent each of over weight and under weight subjects. - 49 -TABLE IV COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY WEIGHT Weight Individual Group instruction instruction Over-Weight 10 12 Average-Weight 5 6 Under-Weight 15 12 T o t a l 30 30 Type of Incision Table V gives the comparative distr ibution of subjects by type of inc is ion. The distributions were highly similar in both groups. There was a larger proportion of subjects with upper abdominal incision in both individual and group instruction (66.6 percent in individual instruction and 73.3 percent in group instruction). - 50 -TABLE V COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY TYPE OF INCISION Type of Incision Individual Group instruction instruction Upper-abdominal 20 22 Lower-abdominal 10 8 T o t a l 30 30 ANALYSIS IN RELATION TO HYPOTHESES The data obtained on the three dependent variables of the study were analysed s t a t i s t i c a l l y in order to compare the results between individual and group instruction. Hypothese I and III were tested by means of t test analysis. The Chi-square test of s ign i -ficance using a 2 x 2 contingency table was used to test hypothesis II. The level of significance was set at .05 for a l l the tests. Hypothesis I The f i r s t hypothesis of the study was: there is no significant difference in the postoperative performance of deep breathing, coughing, and bed exercises by subjects receiving the individual instruc-- 51 -tion as compared with subjects receiving the group instruction. Table VI shows the comparison of subjects in individual and group instruction by their score on performance. The t test analysis revealed no signif icant difference between individual and group instruction on their score on performance of deep breathing, coughing, and bed exercises. However, the mean score for group instruction was higher for a l l the exercises. The null hypothesis was accepted in this test . Hypothesis II The second hypothesis was: there is no signif icant difference in the incidence of postoperative complications for subjects receiving the individual instruction as compared with sub-jects receiving the group instruction. Analysis of the data showed that of the total six complications, four occured in the individual instruction category. A chi-square test of signif icance, using a 2 x 2 contingency table, showed that this difference was not signif icant at .05 leve l . The test result is shown in Table VII. Accordingly, the null hypothesis was accepted. Examination of the data revealed that a l l postopera-tive complications were pulmonary, in both individual and group instruction category. This finding concurs with the l i terature that TABLE VI COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING, AND BED EXERCISES Type of exercise Mean score for individual instruction (N=30) Mean score for group instruction (N=30) d.f. t Value Level of significance .05 Deep breathing 9.87 10.17 58 .35 (not signif icant) Coughing 3.13 3.27 58 .14 (not signif icant) Bed exercises 3.93 4.47 58 1.09 (not signif icant) T o t a l 16.93 17.91 58 .96 (not s ignif icant) P > .05 - 53 -TABLE VII COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS Postoperative Individual Group T o t a l complications instruction instruction N = 20 N = 20 Had complications No complications 26 28 54 p = .74 (not s ignif icant) A P > .05 - 54 -pulmonary complications are more common than circulatory ones. Hypothesis III The third hypothesis was: there is no signif icant difference in the length of hospital stay for subjects receiving the individual instruction as compared with subjects receiving the group instruction. The test results are shown in Table VIII. The mean length of hospital stay for subjects receiving the group instruction was shorter than for subjects receiving the individual instruction (7.77 days as compared to 8.93 days). This findings was not s ignif icant when subjected to the t test analysis (t = 1.29). The null hypo-thesis was accepted. - 55 -TABLE VIII COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY LENGTH OF HOSPITAL STAY INDIVIDUAL INSTRUCTION GROUP INSTRUCTION N = 30 N = 30 Length of stay in days Length of stay in days 8 4 6 8 4 6 12 4 7 19 7 4 5 8 4 4 10 5 8 10 10 9 10 10 13 9 6 9 8 18 9 5 20 9 9 10 12 13 9 11 4 8 10 5 9 7 7 4 9 10 8 7 4 6 7 9 9 5 13 8 X = 7.77 S = 2.51 1 = 8.93 S = 4.25 d.f . - 58 t = 1.29 (not signif icant) p > .05 - 56 -RELATIONSHIP BETWEEN THE SELECTED CHARACTERISTICS AND THE EFFECTIVENESS OF INDIVIDUAL AND GROUP INSTRUCTION The data on the selected characteristics of the subjects and the dependent variables of the study were analysed in order to determine i f there was a relationship between one or more of the characteristics and the effectiveness of individual and group instruction. Relationship Between Selected Characteristics and the Performance  of Exercises The selected characteristics of age and type of incision were analysed to'determine i f there was a relationship between these two characteristics and the performance of exercises. The data in relation to the time of analgesic administration were also compared with the performance of exercises, to determine i f there was a relationship between pain and the performance of exer-cises. Relationship between age and performance of  exercises. Table IX shows the test results of the relationship between age and score on performance of deep breathing, coughing, and bed exercises for subjects, receiving individual and group instruc-t ion. The Pearson product-moment correlation test showed no s ign i -f icant relationship between age and score on performance of exercises in either individual or group instruction category. TABLE IX RELATIONSHIP BETWEEN AGE AND THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING, AND BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION Deep breathing INDIVIDUAL INSTRUCTION N = 30 Coughing Bed exercises Deep breathing GROUP INSTRUCTION N Coughing = 30 Bed exercises Mean score Mean age Coefficient of correlation 9.87 47.87 3.13 47.87 .14 .00 (not signif icant) 3.93 47.87 .09 10.17 44.37 3.27 44.37 4.47 44.37 ,15 .18 (not significant) ,12 P > .05 - 58 -Relationship between type of incision and performance  of exercises. The relationship between the type of incision and the score on performance of deep breathing, coughing, and bed exercises, as measured by the evaluation guide of performance too l , is indicated in Table X. A t test analysis of the data showed similar relationship in both individual and group instruction. No signif icant relationship between type of incision and score on performance of exercises was obtained in either individual or group instruction category. Relationship between administration of analgesic  and performance of exercises. Date on the time of analgesic administration were compared with the score on performance of exercises, for subjects receiving individual and group instruction. The comparison is shown in Table XI. The results indicate that the mean score on performance of deep breathing, coughing, and bed exercises for subjects, who received analgesics within one to four hours before performance, was higher than those who received analgesic less than one hour before and more than four hours before performance. This effect of analgesic upon performance of exercise was similar in individual and group instruction. TABLE X RELATIONSHIP BETWEEN TYPE OF INCISION AND THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING, AND BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 Mean score hrpSth?„„ C o u 9 h i n g B e d breathing 3 3 exercises GROUP INSTRUCTION N Mean score Deep breathing Coughing 30 Bed exercises Upper Abdominal incision 9.25 3.05 4.25 10.18 3.23 4.55 Lower abdominal incision 11.5 3.30 3.30 8.88' 3.38 3.75 d.f. t value 28 1.64 28 .33 28 1.25 28 1.04 28 ,21 28 1.06 (not s ignif icant) (not signif icant) P > .05 TABLE XI RELATIONSHIP BETWEEN ANALGESIC ADMINISTRATION AND THE SCORE ON PERFORMANCE OF DEEP BREATHING, COUGHING, AND BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION Length of time subject had analgesic before exercise performance MEAN SCORE ON PERFORMANCE Deep breathing *I(N=4) *G(N=8) Coughing I(N=20) G(N=17) Bed exercises I(N=6) 6(N=5) 1/2 - 1 hour 1 - 4 hours ^> - 4 hours 9.5 10.45 6.5 10.12 10.75 7.6 3.45 2.16 3.62 3.52 2.2 4.5 2.66 3.5 4.94 3.2 *I *G = Individual Instruction = Group Instruction - 61 -Relationship Between Selected Characteristics and the Incidence of  Postoperative Complications Table XII shows the relationship between the selected characteristics of age, sex, smoking habits, weight, and type of incision and the incidence of postoperative complications for sub-jects receiving individual and group preoperative instruction. No s ta t i s t i ca l tests were applied since the number of complications was small. The data revealed that a l l the six complications occurred in subjects with upper abdominal incis ions. Both complications in group instruction and two of the four complications in individual instruction occurred in subjects between f i f t y - s i x and seventy-two years of age. Subjects who were over-weight had both the complications that occurred in the group instruction category. The other charac-te r i s t i cs did not show any relationship. Relationship Between Selected Characteristics and Length of Hospital  Stay Data on age, sex, smoking habits, weight and type of incision were analysed to determine the relationship between these and the length of hospital stay, for subjects receiving individual and group instruction. - 62 -TABLE XII RELATIONSHIP BETWEEN THE SELECTED CHARACTERISTICS AND THE INCIDENCE OF POSTOPERATIVE COMPLICATIONS IN INDIVIDUAL AND GROUP INSTRUCTION Selected characteristics Number of complications *I *G Number of subjects I G Age (years) 16 - 35 36 - 55 56 - 75 1 1 2 0 0 2 9 11 10 9 12 9 Sex Male Female 3 1 20 10 16 14 Smoking habits Heavy smoker Light smoker Non smoker 2 1 1 1 0 1 16 2 12 13 3 14 Weight Over-weight Average-weight Under-weight 1 1 2 2 0 0 10 5 15 12 6 12 Type of incision Upper-abdominal Lower-abdominal 4 0 2 0 20 10 22 8 T o t a l 30 30 *I = Individual instruction *G = Group instruction - 63 -Relationship between age and length of hospital  stay. Table XIII shows the relationship between age and the length of hospital stay for subjects receiving individual and group instru-ction. No signif icant relationship was obtained in either i n d i v i -dual or group instruction, when the data were subjected to Pearson product-moment correlation test . Relationship between sex and length of hospital  stay. There was a signif icant relationship between sex and the length of hospital stay for subjects receiving individual and group instruction, when the data were subjected to a t test analysis. The mean length of hospital stay for females, in both groups, was s ignif icant ly higher than for males. This is shown in Table XIV. Relationship between smoking habits and length of  hospital stay. Table XV shows the relationship between smoking habits and length of hospital stay, for subjects receiving individual and group instruction. A t test analysis of the data showed no signif icant relationship. Light smokers were excluded from the s t a t i s -t i ca l test , since the number was very small. - 64 -TABLE XIII RELATIONSHIP BETWEEN AGE AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION GROUP INSTRUCTION N = 30 N = 30 Mean age 47.87 44.37 Mean length of stay in days 8.93 7.77 Coefficient of correlation .36 .29 (not signif icant) (not signif icant) P > .05 - 65 -TABLE XIV RELATIONSHIP BETWEEN SEX AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Number of Mean length Number of Subjects of stay in Subjects days Mean length of stay in days Male Female 20 10 7.45 11.3 16 14 6.71 8.75 d.f . t value 28 2.46 28 2.44 (significant at .05 level) (signif icant at .05 level) P < .05 - 66 -TABLE XV RELATIONSHIP BETWEEN SMOKING HABITS AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Number of Mean length Number of Mean length Subjects of stay in Subjects of stay in days days Heavy- 16 8.19 13 8.08 smoker Non-smoker 12 8.55 14 7.21 d.f . 25 25 t value .22 .81 (not signficiant) (not signif icant) P > .05 - 67 -Relationship between weight and length of  hospital stay. The s t a t i s t i c a l test of analysis of variance was applied to the data in weight, to determine i t s relationship to the length of hospital stay. No s ignif icant relationship between weight and the length of hospital stay, was obtained in either group. The result is shown in Table XVI. TABLE XVI RELATIONSHIP BETWEEN WEIGHT AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Number of Mean length Number of Mean length subjects . of stay in subjects of stay in days days Over-weight 10 9.1 12 8.91 Average-weight 5 7.2 6 7.5 Under-weight 15 9.06 12 7.33 d. f . SS MS d. f . SS MS Treatment 2 14.73 7.36 Treatment 2 16.92 8.45 Error 27 532.63 19.72 Error 27 203.08 7.52 F rat io = (2,27) = .37 F rat io = (2,27) = 1.13 (not s ignif icant) (not s ignif icant) P > .05 - 68 -Relationship between type of incision and length of  hospital stay. The relationship between type of incision and the length of hospital stay was signif icant at a l l known leve ls , for both individual and group instruct ion, as obtained by t test analysis. The results are shown in Table XVII which indicates that the subjects with upper abdominal incisions had a s igni f icant ly longer hospital stay. TABLE XVII RELATIONSHIP BETWEEN TYPE OF INCISION AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Number of subjects Mean length of stay in days Number of subjects Mean length of stay in days Upper abdominal 20 incision 10.6 22 8.91 Lower abdominal 10 incision 5.1 4.63 d.f . 28 28 t value 4.04 (significant at a l l (signif icant at a l l known levels) known levels) P <C .05 - 69 -SUMMARY The analysis of the data and the findings are presented in this chapter. A comparison of subjects receiving * individual and group instruction revealed high s imi lar i ty between the two groups. The analysis of the data in relation to the hypo-theses of the study revealed no signif icant difference between the effectiveness of individual and group instruction and the null hypotheses were consequently accepted. There was no signif icant relationship between the selected characteristics of the subjects and the effectiveness of individual and group instruction. The re -sults were similar in both groups. CHAPTER V SUMMARY, FINDINGS, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS SUMMARY The purpose of this study was to compare the effectiveness of individual and group preoperative instruct ion. The specif ic questions asked in this study were: 1. Is group preoperative instruction in deep breathing, coughing, and bed exercises as effective as individual instruct ion, as measured by the postoperative performance of these exercises, the incidence of postoperative complications, and the Icnguii Oi n u i p l u a i z>L,ay: 2. Is there a relationship between the selected characteristics of the subjects (age, sex, smoking habits, weight, and type of incision) and the effectiveness of individual and group preoperative instruction? The following hypotheses were tested in the study: 1. There i s no s igni f icant difference in the post-operative performance of deep breathing, coughing, and bed exercises by subjects receiving the individual instruction as compared with subjects receiving the group instruct ion. 2. There i s no s igni f icant difference in the i n -cidence of postoperative complications for subjects receiving indivdiual instruction as compared with subjects receiving group instruct ion. - ZO -- 71 -3. There is no signif icant difference in the length of hospital stay for subjects receiving individual instruction as compared v/ith subjects receiving group instruct ion. The l i terature reviewed in the study emphasized the need for preoperative instruct ion, to promote postoperative recovery. Postoperative deep breathing, coughing, and bed exercise measures prevent or minimize pulmonary and circulatory complications. The study assumed that group instruction is one possible means by which most surgical patients can be assured adequate preoperative instruct ion. The study was conducted in one surgical f loor of a large general hospital . Subjects included sixty adult surgical patients, who met the c r i te r ia of the study. The subjects were alternately assigned, by week, to either individual or group pre-operative instruction. A preoperative instruction booklet, spec i f ica l ly devised for the study, was used to ensure consistency in teaching between the researcher and the preoperative teaching nurse who also instituted the preoperative instruct ion. The data, using the patient prof i le sheet, were collected by the researcher. The physiotherapist evaluated the performance of exercises. The data were collected for a period of eight weeks. - 72 -The data were analysed as follows: 1. The subjects receiving individual instruction and the subjects receiving group instruction were compared on the selected characteristics of age, sex, smoking habits, weight, and type of inc is ion. 2. A t test was applied to the data in relation to hypothesis I and hypothesis II I . A chi-square test of significance using a 2 x 2 contingency table, was applied to data in relation to hypothesis I I . 3. The relationship between the selected character-i s t i cs of the subjects and the effectiveness of individual and group instruct ion, was determined. FINDINGS Subjects in individual and group instruction were highly similar in relation to the selected characteristics of the study. The mean age for individual instruction was 47.87 years and for group instruction i t was 44.37 years. Comparatively, there were more males than females in both individual and group instruct ion. The l ight smokers were few in number in both individual (two out of thirty) and in group (three out of thirty) instruction. Subjects with average weight (16 percent in individual instruction and 20 percent in group instruction) were fewer in proportion as compared to subjects with over-weight or under-weight. There was a larger - 73 -proportion of subjects with upper abdominal surgery (66.6 percent in individual instruction and 73.3 percent in group instruction) as compared to subjects with lower abdominal surgery. The t test analysis of the data in relation to hypo-theses I and III showed no signif icant difference between individual and group instruction. However, the mean score on performance of deep breathing, coughing, and bed exerciseswas higher, and the mean length of stay was shorter for subjects receiving the group instruction. Consequently hypotheses I and III were accepted. Data in relation to hypothesis I I , when tested using a chi-square test of signif icance, showed no difference between subjects receiving individual instruction and subjects receiving group instruct ion, in the incidence of post-operative complications. However there were only two subjects who had complications in group instruction as compared to four subjects in individual instruction. The insignif icant result may have been attributed to the small sample s ize . The relationship between age and the three dependent variables of the study, was determined. No signif icant relationship was obtained between age and these variables of the performance of exercises, the incidence of postoperative complications, and the length of hospital stay. Age did not alter the effectiveness of instruction in either individual or group method. The relationship between type of incision and performance of exercises was determined by t test analysis. No signif icant relationship was determined in either groups. i - 74 -The number of complications were too small (four in individual instruction and two in group instruction) to apply any s ta t i s t i ca l test on this data, in order to determine the re lat ion-ship between incidence of postoperative complications and the selected characterist ics. The data showed that a l l the compli-cations occured in subjects with upper abdominal inc is ion. Subjects between the ages of f i f t y - s i x and seventy-five had four out of six complications. The relationship between these variables were similar in individual and group instruction. In order to determine the relationship between selected characteristics and the length of hospital stay, a corre-lation test was applied to the data. No signif icant relationship between these two variables was obtained. Data on type of inc is ion , smoking habits, and sex were subjected to t test analysis. Smoking habits showed no s ign i -f icant relationship. Sex and type of incis ion were s igni f icant ly related to the length of hospital stay. Females had a s igni f icant ly longer hospital stay. Length of hospital stay for subjects with upper abdominal incision was s igni f icant ly longer. Relationship between weight and length of hospital stay was determined by the s t a t i s t i c a l test of analysis of variance. No signif icant relationship between these two variables was obtained. - 75 -CONCLUSIONS The following conclusions are drawn from the findings of the study: 1. Group preoperative instruction is as effective as individual preoperative instruction. In the present study the effectiveness of preoperative instruction was measured by the postoperative performance of deep breathing, coughing, and bed exercises; the incidence of postoperative complications; and the length of hospital stay, in individual and group instruction. The mean score on performance was higher, the mean length of stay was shorter and the number of complications were fewer for subjects receiving group instruction .as compared with subjects receiving individual instruction. These differences were not signif icant when s t a t i s t i c a l l y tested. It is recognized by the investigator that a number of other factors do influence the dependent variables in the study. The random assignment of the subjects to individual and group i n -struction, and ensuring r e l i a b i l i t y and va l id i ty of the tools , were measures taken to control these factors. 2.. Group preoperative instruction is just as effect -ive as individual instruction for patients regardless of their age. No signif icant relationship was obtained between age and the three dependent variables of the study in individual and group preoperative instruction. Literature had indicated that individual - 76 -instruction might be necessary for older patients. Findings of this present study revealed that group preoperative instruction was just as effective as individual instruction for subjects in the older age group. The group effect may have compensated for the differences in the older subjects. The present study showed that older patients are able to learn through small group instruction method. 3. Weight and smoking habits of subjects did not alter the effectiveness of individual and group preoperative instruction. Previous work had indicated that smoking habits and over-weight do interfere with the postoperative recovery. The present study showed no signif icant relationship between these factors and the three dependent variables in the study. This might be due to the fact that the effects of smoking habits and over-weight may be compensated by the effect of preoperative instruction. However the results were similar for subjects receiving individual and subjects receiving group instruction. 4. There is a signif icant relationship between sex and length of hospital stay. The study showed that females had a s igni f icant ly longer hospital stay than males in individual and group instruction Since the incidence of complications was similar in males and females, this result might not be related to the effectiveness of instruction. One reason for this difference may be the type of inc is ion. More - 77 -male patients had lower abdominal surgery than female patients, and the mean length of hospital stay for lower abdominal incision was signif icantly lower than for upper abdominal inc is ion. A l l the subjects who had inguinal hernia repairs were males. Table XXXII in Appendix D shows the comparison of subjects by type of surgery and by sex. 5. There is a signif icant relationship between type of incision and length of stay. Findings of the study showed that subjects with upper abdominal incision had a longer hospital stay as compared with sub-jects having lower abdominal surgery. This finding was due to the obvious fact that upper abdominal surgeries were major operations whereas lower abdominal surgeries consisted mainly of inguinal hernia repairs. 6. Postoperative complications are more common among subjects with upper abdominal surgery than subjects with lower abdominal surgery. The findings of the study revealed that a l l of the six subjects who had postoperative chest complications were subjects with upper abdominal surgery. This result concurs with previous research findings. - 78 -7. Pulmonary complications are more frequent than circulatory complications. A l l six postoperative complications were either atelectasis or pneumonia. Literature has supported this f inding. 8. Group preoperative instruction is more e f f i -cient than individual instruction. Observation during the procedure of the study re-vealed that teaching in groups saved time. Individual instruction involved comparatively longer time and made i t inconvenient to plan other nursing a c t i v i t i e s . Comments from nursing staff and patients were in favour of group instruction. Thus, considering i t s advantages of economy of time and fewer number of personnel required, group instruction is more ef f ic ient than individual instruction. IMPLICATIONS The major obstacles to patient teaching have been identif ied as'lack of time, heavy work load and understaffingJ The necessity for improving the quality of instruct ion, despite the increasing number of patients requiring health teaching is a Margaret L. Pohl, "Teaching Act iv i t ies of the Nursing Practit ioner," Nursing Research, XIV (Winter, 1965), 11. - 79 -d i f f i c u l t y facing the nursing profession. The present study revealed that group instruction is as effective as individual instruction. However this finding is l imited to the preoperative instruction in deep breathing, coughing, and bed exercises as demonstrated by this study. The findings of this study have the following implications: 1. Group preoperative instruction, as a means to provide adequate instruction to most surgical patients, should be tr ied out in hospital settings. Graduate nurses should be oriented to structured instruction in small groups. 2. Schools of nursing should include in their c u r r i -culum, the dynamics of group instruction, in relation to health teaching. RECOMMENDATIONS Based on the findings of the present study following recommendations for further research are suggested: 1. Replicate the present study using three groups of subjects; one receiving individual instruct ion, one receiving group instruction, and one receiving no structured instruction. The lack of a control group has been a. l imitat ion of the present study. 2. Studies to compare the effectiveness of i n d i v i -dual and group preoperative instruction in areas other than deep breathing, - 80 -coughing, and bed exercises,need to be undertaken. 3. Before the results of this study can be general-ized to surgical patients at large, the study should be replicated in different settings using a larger number of subjects. 4. Further research investigating the effectiveness of group instruction for older patients, would be of value. 5. Findings of the present study revealed that female patients had a significantly longer hospital stay as compared to male patients. This conclusion needs further investigation before i t can be generalized. BIBLIOGRAPHY - 81 -- 82 -A. BOOKS Ayers, S. and S. Giannell is . Care of the C r i t i c a l l y 111. New York: Appleton-Centure-Crofts, 1967. Bendixen, H. H., and Others. Respiratory Care. Saint Louis: The C. V. Mosby Co., 1965. Brunner, L i l l i a n S . , and Others. Medical Surgical Nursing. 2nd ed. Toronto: J . 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Care of the Adult Patient: Medical Surgical Nursing. 3rd ed. Toronto: J . B. Lippincott Co., 1971. Thomas, George and Joseph Crescimberni. Individualizing Instruction in the Elementary School. New York: Random House, 1967. - 83 -B. PERIODICALS Anderson, W. H., B. E. Dorsett, G. L. Hamilton. "Prevention of Postoperative Pulmonary Complications," Journal of  American Medical Association, CLXXXVI (November 23, 1963), 763-766. Anscombe, A. R., and Rogert St. J . Buxton. "Effects of Abdominal Operations on Total Lung Capacity and Its Subdivisions. Br i t ish Medical Journal, II (July 12, 1958), 84-87. Bendixen, H. H., J . Hedley-White, and M. B. Laver. "Impaired Oxygenation in Surgical Patients During General Anesthesia with Controlled Venti l lat ion (A Concept of Atelectasis) , " New England Journal of Medicine, CCLXIX (November 7, 1963?, 991-996 Berecek, Kathleen H., and Susan L. Janson. "Influence of Postanes-thetic Suggestion on Prevention of Postoperative Pulmonary Complications," CHEST, LXI (March, 1972), 240-246. Cashel Weiler, Sister M. "Postoperative Patients Evaluate Preopera-tive Instruction," American Journal of Nursing, LXVIII. (July, 1968), 1465-1467. Donabedian, Avedis. "Evaluating the Quality of Medical Care," The Milbank Memorial Fund Quarterly, XLIV, No.3, Part 2 (July, 1966), 166-207. Dripps, R. D., and M. V. Deming. "Postoperative Atelectasis and Pneumonia: Diagnosis, Etiology, and Management Based on 1,240 Cases of Upper Abdominal Surgery," Annals of Surgery, CXXIV (July, 1946), 94-110. Dripps, Robert D. and R. M. Waters. "Nursing Care of Surgical Patients I. The 'S t i r -Up ' , " American Journal of  Nursing, XLI (May, 1941), 530-534. Egbert, L. D., and Others. "Effect of Site of Operation and Type of Anesthesia Upon the Ab i l i t y to Cough in the Post-operative Period," Surgery, Gynecology, and Obstetrics, CXV (September, 1962), 295-298. - 84 -Egbert, L., and Others. "Reduction of Postoperative Pain by Encourage-ment and Instruction of Patients," New England  Journal of Medicine, CCLXX (April 16, 1964), 825-827. E l l i son , Lois T., and Others. "Oxygen Requirements in the Early Postoperative Period (48 hours): Ventilation and Respiratory Exchange," Annals of Surgery, CLXIII (Apr i l , 1966), 559-566. Haar, Doris J . "Improved Phenylketonuric Diet Control Through Group Education of Mothers," Nursing CIinics of  North America, I (December, 1966), 715-723. Hallburg, Jeanne C. "Teaching Patients Self Care," Nursing Cl in ics  of North America, V (June, 1970), 223-231. Hamilton, W. K. "Atelectasis, Pneumothorax, and Aspiration as Post-operative Complications," Anesthesiology, XXV (September - October, 1961), 708-722. Healy, Katherine M. "Does Preoperative Instruction Make a Difference?," American Journal of Nursing, LXVIII (January, 1968), 62-67. Levine, Eugene. "Experimental Design in Nursing Research," Nursing  Research, IX ( F a l l , 1960), 203-212. Lewis, John F. and John H., Welch. "Respiratory Mechanics in Post-operative Patients," Surgery, Gynecology, and Obstetrics, CXX (February, 1965), 305-314. Lindeman, C. A. "Nursing Intervention With the Presurgical Patient -Effectiveness and Efficiency of Group and Individual Preoperative Teaching," Nursing Research, XXI. (May - June, 1972), 196-208. Lindeman, C. A. and B. Van Aernam. "Nursing Intervention With the Presurgical Patient - The Effects of Structured and Unstructured Properative Teaching," Nursing Research, XX. (July - August, 1971), 319-332. Mezzanotte, Elizabeth J . "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. (Winter, 1964), 26-33. - 85 -Nickerson, Donna. "Teaching the Hospitalized Diabetic," American  Journal of Nursing, LXXII . (May, 1972), 935-939. Palm, Mary L. "Recognizing Opportunities for Informal Patient Teaching," Nursing Cl inics of North America, VI (December, 1971), 669-678. Packard, R. B., and H. Van Ess. "A Comparison of Informal and Role-Delineated Patient Teaching Situations," Nursing  Research, VII (September - October, 1969), 443-446. Pohl, Margaret L. "Teaching Act iv i t ies of the Nursing Pract i t ioner ," Nursing Research, XIV (Winter, 1965), 4-11. Redman, Barbara K. "Patient Education as a Function of Nursing Practice," Nursing Cl inics of North America, VI (December, 1971), 573-580. Schmitt, Florence E., and Powhatan J . Wooldridge. "Psychological Preparation of Surgical Patients," Nursing Research, XXII (March - A p r i l , 1973), 108-115. S tor l ie , Francis. "A Philosophy of Patient Teaching," Nursing  Outlook, XIX (June, 1971), 387-389, Ward, R. J.,and Others. "An Evaluation of Postoperative Respiratory Maneuvers," Surgery, Gynecology, and Obstetrics, CXXXIII (July, 1966), 51-54. Wightman, J . A. K. "A Prospective Survey of the Incidence of Post-operative Pulmonary Complications," Br i t ish Journal  of Surgery, LV (February, 1968), 85-91. C. UNPUBLISHED WORKS Goodman, Gertrude Warkentin. "An Experimental Study to Evaluate the Effect of Planned Teaching on Self-Medication Practices of Older Ambulatory Cardiac Patients," Unpublished Master's thesis, University of Br i t i sh Columbia, 1972. Power, Denise Mary. "The Effectiveness of Planned Teaching of Mothers With Children Treated in Emergency Departments," Unpublished Master's thesis, University of Br i t ish Columbia, 1972. - 86 -Skelton, Judith Mary. "An Experimental Study to Evaluate the Effective-ness of a Diabetic Teaching Tool," Unpublished Master's thesis, University of Br i t ish Columbia, 1973. Wyness, Margaret Anne. "An Examination, Over a Specified Time Period of the Effect of Deep Breathing, Coughing, and Turning Frequency on the Respiratory Function of Selected Patients with Abdominal Surgery," Unpublished Master's thesis, University of Washington, 1972. D. PERSONAL INTERVIEWS Baines, Marilyn. Acute Care Instructor, St. Paul's Hospital, Vancouver, B.C. Personal interview - September, 1973. Hunter, Margaret. Senior Instructor, Rehabilitation Medicine, Uni-versity of Br i t ish Columbia, Vancouver, B.C. Personal interview - May, 1973. McMahon, Brian. Television Production Manager, Biomedical Communications, University of Br i t ish Columbia, Vancouver, B.C. Personal interview - May, 1973. Pagan, Wilma. Preoperative Teaching Nurse, St. Paul's Hospital, Vancouver, B.C. Personal interview - May, 1973. Perry, JoAnn. Respirology Nurse C l in i c ian , St. Paul's Hospital, Vancouver, B.C. Personal interview - September, 1973. Skelton, Judith M. Instructor, University of Br i t ish Columbia, Vancouver, B.C. Personal interview - September, 1973. APPENDIX A The Preoperative Instruction Tools The Booklet The Practice Guide - 87 -- 88 -FOR A BETTER RECOVERY AFTER YOUR SURGERY AIM INSTRUCTION BOOKLET OF "PREOPERATIVE TEACHING OF DEEP BREATHING, COUGHING AND BED EXERCISES" - 89 -INTRODUCTION The purpose of this conference is to help you learn certain exercises which you are expected to do after your surgery. The exercises you wi l l be learning are: a. Deep breathing b. Coughing c. Bed exercises These exercises are done as routine measures to pro-mote optimum recovery after your surgery. Doing these exercises during the postoperative period w i l l help in preventing chest and circulatory problems. Speedy recovery from surgery is attained by preventing these problems. Although the nurse and the therapist w i l l assist you with the exercises, i t is important that you know how to do them. - 9G -POSTOPERATIVE EXERCISES A. DEEP BREATHING B. COUGHING C. BED EXERCISES - 91 -Why You Should Do These Exercises These exercises w i l l aid in improving breathing and circulation and thus prevent problems after surgery. The normal breathing and circulat ion is depressed more after surgery, therefore special effort must be made in order to obtain and maintain proper breathing and blood c i rcu lat ion . This is mainly accomplished by deep breathing, coughing and bed exercises. - 92 -EXERCISES AFTER SURGERY IMPROVE BREATHING AND CIRCULATION - 93 -How Often Should You Do These Exercises? You should do these exercises as frequently as you can, or at least every two hours. Do the exercises whenever you are awake and remember about them. Start doing them soon after you come out of anesthesia. The earl ier you start doing them, the better i t i s . A certain amount of pain is expected after surgery, but a needle w i l l be ordered for you for the pain. If you are in pain and unable to do the exercise, please ask the nurse for a 'pain k i l l e r ' . - 94 -DO YOUR EXERCISE AT LEAST EVERY TWO HOURS - 95 -What are the Factors that Lead to Poor Breathing and Circulation After  Surgery? 1. The medicines and anesthetics you receive for surgery tend to slow down your circulation and breathing. 2. Smoking i r r i ta tes the membrane l in ing the res-piratory tract and increases secretion. This may block the tiny a i r passages in the lungs. Therefore i t is very important that you do not smoke at least from the day before surgery t i l l you recover. 3. Pain after surgery leads to spl inting of the chest and abdominal muscles, which interferes with breathing. 4. Lack of movement after surgery inhibits drainage of secretion from the lungs. Retained secretions in the lungs may lead to pneumonia. Lack of movement also fac i l i ta tes inflammation and forma-tion of clot in veins. - 96 -AVOID SMOKING FROM NOW TILL YOU RECOVER - 97 -How to do the Postoperative Exercises A. Deep Breathing  Purpose It helps to expand the lungs and thus imporves breathing. It consists of: Abdominal breathing Chest breathing The important muscles that help in this breathing are: Diaphragm and Intercostals, that are shown in the picture. - 98 -MUSCLES OF BREATHING - 99 -How to do Deep Breathing Begin by getting into a comfortable posit ion. You may l i e on your back with head raised as shown in this picture. It may be necessary for you to remain f l a t on bed, depending on the nature of your surgery. Lying on your side, or s i t t ing up at the edge of the bed are also comfortable positions for deep breathing. You may use a l l of these positions at various times. - 100 -LYING ON BACK - 101 -Deep breathing is best done in two steps. 1. Abdominal Breathing This is done mainly with your diaphragm. It aids in bowel action and re l ie f from gas. Breathe in slowly and deeply through your nose, lett ing your upper abdomen r ise up. Hold the breath for a few seconds. A deep breath when held, is more effect ive. Now breathe out through your mouth with part ia l ly closed l i p s . Your abdomen draws back as you breathe out. (Nurse demonstrates this) - 102 -ABDOMINAL BREATHING. LET ABDOMEN RISE UP & OUT AS YOU BREATHE IN. - 103 -2. Chest Breathing This is done mainly with your intercostal muscles. It expands the lower chest. It also aids in bringing up secretion. Breathe in slowly and deeply through your nose, lett ing your lower chest move out. Hold the breath for a few seconds. Now breathe out through your mouth with l ips par t ia l l y closed. Your chest wall is drawn in as you breathe out. (Nurse demonstrates this) This exercise is important after surgery as i t expands the lower chest, because i t is the lower part of your lungs that are often not used after surgery. - 104 -CHEST BREATHING. LET LOWER CHEST RISE UP & OUT AS YOU BREATHE IN. - 105 -B. Coughing The next exercise is 'coughing' and is done after the deep breathing exercise. Purpose It expands the lungs It brings up secretions How to do i t This can be painful , therefore supporting the incision using a pillow as shown in this picture, w i l l help to minimize pain. Take a deep breath in as for the Ueep breathing exercise' and 'hu f f 'air out, and then cough. (A 'hu f f is a short sharp breath out.) When you huff, do not exhale a l l the a i r out, because the cough would then become ineffective. The cough must come from the lower part of your chest and not just from the throat. The 'huf f tends to loosen the secretions and make the cough less painful and more effective. Make sure you have kleenex and garbage bag handy when you do the coughing. (Nurse demonstrates the coughing exercise) - 107 -C. Bed Exercises are the next important exercise. They include 1. Leg and foot exercises 2. Turning from side to side Purpose 1. Improve circulat ion 2. Prevents clot formation 3. Prevents muscle weakness 4. Improves breathing 5. Promotes drainage of secretion from lungs - 108 -BED EXERCISES. LEG AND FOOT EXERCISES & TURNING . - 109 -1. Leg and Foot Exercise Do these exercises slowly. Repeat them 2 - 3 times each and relax in between. How to do them 1. With your heels and legs resting on the mattress, press or point the toes of your both feet toward the foot of the bed and then toward your chin until the cal f muscles tighten and then relax. 2. With your legs straight and resting on bed, draw a c i r c le with each of your feet, in both directions, moving them at the ankles. 3. With your one foot resting on the bed, s l ide i t along the mattress unti l your knee is bent, as shown in this picture. Now sl ide i t back, relax and do the same with the other leg. Now there are 3 important leg and foot exercises. They are pointing the toes of your foot up and down, drawing a c i r c le with your feet and bending your knees. - no -LEG EXERCISE - in -2. Turning  Purpose 1. Promotes drainage of secretion 2. Improves circulation You might need assistance to turn depending on the nature of your surgery, and the number of tubes and drains that you may have. You should change your position every 2 - 4 hours. Lie on each side as well as on your back, unless otherwise instructed. How to do i t To turn from your back to the right side: F i rst bend both your knees L i f t buttock and move to the l e f t , with nurse helping you to move your head and shoulders as shown in this picture Now bend your l e f t leg more placing your foot firmly on the bed - 112 -TURNING STEP I - 113 -Now move your l e f t arm over and grasp the side ra i l as shown in this picture. Roll on to your right side pushing with your l e f t foot. The nurse wi l l probably support your back with a pillow as you see in this picture. The same procedure in reverse is used to turn on to your l e f t side. Rolling on to your side l ike a log usually reduces pain. - 114 -TURNING STEP I I - 115 -This picture shows you actually lying on one side. You may find this a comfortable and easier position to cough. When you are ready to turn on to your back, bend the knee of your upper leg , place the tope hand on the mattress and push yourself over. Turning is done easier, by bending your knees, grasp-ing the side r a i l and ro l l ing l ike a log on to your side. - 117 -5. Summary In summary there are three main exercises you should do after your surgery. They are deep breathing, coughing and bed exercises. The bed exercises include leg exercises and turn-ing. Therapists and nurses wi l l assist you, but i t is important that you cooperate and do them as well as you can. The next few minutes I would l ike you to practice these exercises you have just learned, especially deep breathing and coughing. Practice them unti l you are able to do them wel l . Practice these exercises again tonight. This guide is to assist you with your practice. (The nurse hands out the practice guide to each patient) (In group instruct ion, patients are encouraged to ask questions, talk to each other and discuss, during the practice session.) - 118 -A PRACTICE GUIDE FOR DEEP BREATHING, COUGHING, AND BED EXERCISES Deep breathing, coughing, and bed exercises prevent postoperative chest and circulatory problems and thus promote speedy recovery after your surgery. Practice these exercises be-fore your operation so that you know how to do them wel l . Deep Breathing Assume a comfortable position with head s l ight ly elevated and knees bent. Abdominal breathing. Breathe in slowly and deeply through nose, lett ing your abdomen r ise up. Hold the breath for few seconds. Now breathe out through your mouth with l ips par t ia l l y closed. Chest breathing. Breathe in slowly and deeply through your nose letting, your lower chest move out. Hold the breath for few seconds. Now breathe out through your mouth with l ips part ia l ly closed. Coughing Breathe in as for deep breathing exercise, and 'hu f f a i r out and then cough from the lower part of your chest. (Supporting the incision wi l l minimize pain) - 119 -Bed Exercises With your heels and legs resting on bed press your toes of both feet toward the foot of bed and then toward your chin. Draw a c i r c le with each foot in both directions with your legs straight and resting on bed. Bend your knees alternately, s l iding the foot up along bed. Relax in between each exercise. APPENDIX B The Data Collection Tools The Patient Prof i le Sheet The Evaluation Guide of Performance - 120 -- 121 -THE PATIENT PROFILE SHEET Patient Number A. Acje 1. 1 6 - 3 5 years 2. 3 6 - 5 5 years 3. 5 6 - 7 5 years C. Smoking Habits Teaching Method B. Sex 1. Male 2. Female D. Weight 1. Non-smoker (does not smoke) 2. Light-smoker (smokes less than 1/2 package of cigarettes per day or smokes cigars or a pipe) 3. Heavy-smoker (smokes more than 1/2 package of cigarettes per day) E. Type of Incision 1. Upper abdominal incision . (Incisions that extend above umbilicus) 2. Lower abdominal incision (Incisions that are below the umbilicus) 1. Over-weight 2. Average-weight 3. Under-weight Weight Height Age Date of surgery Date of discharge Postoperative complications a. atelectasis b. pneumonia c. thrombophlebitis d. others (specify) - 122 -EVALUATION GUIDE OF PERFORMANCE Patient Number Time of Evaluation Teaching Method Time of Last Analgesic (For comments add any related action that is not included in this l i s t . ) Circle the appropriate actions. (I would l ike you to show me the exercises that you learned yesterday.) A. Deep Breathing (Begin with the deep breathing exercise) a. Assumes a comfortable posit ion. b. Supports the incision while doing the exercise. Abdominal Breathing (Do the abdominal breathing f i r s t ) a. Breathes in slowly and deeply. b. Breathes in through the nose. c. The abdomen rises up and out while breathing i n . d. Holds the breath in for few seconds. e. Breathes out through the mouth. f . Keeps l ips par t ia l l y closed while breathing out. Comments : Chest Breathing (Now show me the chest breathing exercise) a. Breathes in slowly and deeply. b. Breathes in through the nose. c. The lower chest r ises up and out while breathing i n . d. Holds the breath in for few seconds. e. Breathes out through the mouth. f . Keeps l ips par t ia l l y closed while breathing out. - 123 -Comments: B. Coughing (Show me how you cough) a. Assumes a comfortable position (e.g. head s l ight ly elevated and knees bent). b. Supports the inc is ion. c. Breathes in slowly and deeply . d. Breathes in through nose. e. 'Huffs' a i r out. f . Coughs deeply from lower part of chest. Comments: C. Leg and foot exercise (Now do the leg and the foot exercise) a. Lies on back with head s l ight ly elevated. b. Keeps both legs straight and resting on bed. c. Bends each knee s l id ing foot up along bed alternately. d. Pushes toes of both feet toward the foot of the bed and pulls them toward chin. e. Makes a c i r c le with both feet in both directions. f . Relaxes in between each exercise. Comments: APPENDIX C Tables of Stat is t ica l Analysis - 124 -- 125 -TABLE XVIII COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON DEEP BREATHING INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Scores (14 max.) Scores (14 max 12 13, 14 11 13 12 8 11 14 3 6 6 14 5 13 8 13 10 14 13 9 6 14 9 13 6 12 10 14 6 10 12 11 13 6 9 12 5 11 10 8 13 14 7 5 14 4 10 5 5 11 6 13 9 13 14 14 6 7 12 X = 9.87 X = 10.17 S = 3.71 S = 2.94 d.f . = 58 t = .35 P > • 05 (not signif icant) - 126 -TABLE XIX COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON COUGHING INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Scores (6 max.) Scores (6 max .) 4 5 ' 3 3 4 1 3 3 5 0 5 3 5 1 1 5 3 4 2 2 3 3 5 4 5 3 3 3 5 0 5 0 2 2 2 6 6 5 4 4 1 5 3 3 0 0 6 0 3 2 3 3 5 6 4 0 4 2 3 4 X = 3.13 X = 3.27 S = 1.91 S = 1.68 d.f . = 58 • t = .14 P > .5 (not signif icant) - 127 -TABLE XX COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION BY SCORE ON BED EXERCISES INDIVIDUAL Scores INSTRUCTION N=30 (6 max.) GROUP INSTRUCTION N=30 Scores (6 max.) 6 0 5 3 5 5 4 3 3 1 6 5 6 3 3 6 5 2 3 6 6 2 6 6 6 4 5 6 6 5 5 6 5 3 6 5 6 4 6 2 5 5 1 1 0 6 6 4 4 0 6 3 1 4 6 0 5 5 6 4 X = S = 3.93 1.98 X S = 4.47 = 1.8 d.f. = 58 • t = 1.09 P > .05 (not signif icant) - 128 -TABLE XXI RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF DEEP BREATHING IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Age Score Age Score (years) (14 max.) (years.) (14 max.) 22 14 18 10 26 13 19 13 28 13 20 11 29 9 22 8 32 5 25 14 33 14 26 12 35 5 29 6 35 5 29 11 35 12 31 7 43 6 37 7 44 5 38 6 45 14 39 9 45 13 40 12 46 8 40 13 46 10 41 11 48 14 46 14 50 6 48 13 51 9 49 14 52 6 50 14 53 13 55 10 56 11 61 9 58 13 62 8 59 6 62 11 61 14 62 10 61 13 64 6 62 12 64 10 64 13 65 6 70 5 68 14 72 12 69 12 75 3 73 4 X = 47.87 X = 9.53 X = 44.37 X = 1017 r = - .14 (not signif icant) r = - .15 (not signif icant) P > .05 - 129 -TABLE XXII RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF COUGHING IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Age Score Age Score (years) (6 max.) (years) (6 max.) 22 5 18 3 26 5 19 1 28 4 20 3 29 6 22 5 32 2 25 5 33 •0 26 3 35 6 29 3 35 0 29 4 35 3 31 6 43 2 37 3 44 1 38 3 45 5 39 6 45 4 40 2 46 1 40 0 46 4 41 3 48 5 41 3 50 3 46 3 51 3 48 4 52 0 49 2 53 5 50 3 56 2 55 5 58 2 61 4 59 3 62 3 61 5 62 3 61 5 64 0 62 4 64 2 64 3 65 4 70 5 68 5 72 1 69 6 75 0 73 4 X = 47.87 X = 3.13 X = 44.37 X = 3.27 r = 0 (not signif icant) r = - .18 (not signif icant) P > .05 - 130 -TABLE XXIII RELATIONSHIP BETWEEN AGE AND SCORE ON PERFORMANCE OF BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N*30 Age Score Age Score (years) (6 max.) (years) (6 max.) 22 6 18 6 26 0 19 3 28 5 20 3 29 4 22 6 32 0 25 6 33 6 26 5 35 6 29 6 35 0 29 5 35 4 31 6 43 5 37 1 44 3 38 3 45 5 39 5 45 5 40 6 46 5 40 6 46 2 41 5 48 3 41 6 50 4 46 6 51 6 48 3 52 5 49 1 53 1 50 5 56 5 55 6 58 3 61 4 59 2 62 3 61 6 62 4 61 6 64 6 62 6 64 2 64 5 65 6 70 4 68 6 72 5 69 4 75 1 73 0 i = 47.87 X = 3.93 X = 44.37 X = 4.47 r = .09 (not signif icant) r = .12 (not signif icant) P .05 - 131 -TABLE XXIV RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF DEEP BREATHING IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N =30 Score (14 max.) Score (14 max.) Upper abdominal Lower abdominal Upper abdominal "Lower abdominal incision (N=20) incision (N=10) incision (N=22) incision (N=8) 12 13 4 13 13 14 8 4 9 14 6 11 13 8 14 6 14 13 14 8 11 13 12 12 12 12 10 7 5 5 6 10 .5 10 11 14 13 14 3 11 10 13 6 7 6 11 5 13 13 9 14 10 5 9 9 10 6 6 14 12 X = 9. 25 X = 11.5 X = 10.18 X = 8.88 S = 3 78 S = 2.95 S = 3.02 S = 3.14 t = 1.64 (not signif icant) t = 1.04 (not signif icant) d.f . = 28 P > .05 - 132 -TABLE XXV RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF COUGHING IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Score (6 max.) Score (6 max.) Upper abdominal Lower abdominal Upper abdominal Lower abdominal incision (N=20) Incision (N=10) Incision (N=22) incision (N=8) 4 4 3 1 3 5 3 6 3 5 5 3 5 1 2 3 5 5 5 5 2 5 3 0 6 1 5 3 0 1 2 6 3 4 4 4 2 3 0 3 3 4 3 0 0 3 5 2 5 4 0 3 2 6 6 4 2 3 0 4 X = 3.05 X = 3.3 X = 3. 23 X = 3.38 S = 1.99 S = 1.83 S = 1. 48 S = 2.2 t = .33 (not signif icant) d. f . = 28 t = .21 (not signif icant) P > '.'05 - 133 -TABLE XXVI RELATIONSHIP BETWEEN TYPE OF INCISION AND SCORE ON PERFORMANCE OF BED EXERCISES IN INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Score (6 max.) Score (6 max.) Upper abdominal Lower abdominal Upper abdominal Lower abdominal incision (N=20) incision (N=10) incision (N=22) incision (N=8) 6 5 5 3 5 3 4 6 6 6 6 3 6 5 3 5 6 1 6 6 5 0 5 2 6 5 5 1 0 3 6 4 4 2 6 5 3 1 1 6 2 6 4 0 5 3 4 6 5 6 6 6 0 6 4 5 5 2 3 4 X = 4.25 X = 3.3 X = 4. 55 X = 3.75 S = 1.97 S = 1.95 S = 1. 82 S = 1.83 t = 1.25 (not signif icant) d.f . = 28 t = 1.06 (not signif icant) P > .05 - 134 -TABLE XXVII RELATIONSHIP BETWEEN AGE AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION GROUP INSTRUCTION Age ' Length of stay Age Length of stay (years) in days (years) in days 22 8 18 9 26 4 19 4 28 4 20 4 29 6 22 4 32 10 25 10 33 7 26 6 35 12 29 4 35 9 29 9 35 • 9 31 13 43 5 37 5 44 8 38 7 45 8 39 10 45 9 40 5 46 4 40 10 46 5 41 6 48 7 41 8 50 9 46 7 51 10 48 8 52 18 49 10 53 4 50 9 56 20 55 10 58 9 61 12 59 9 62 8 61 5 62 4 61 13 64 9 62 8 64 11 64 10 65 7 70 13 68 7 72 6 69 8 75 19 73 9 X = 47.87 X = 8.77 X = 44.37 X = 7.77 r = .36 (not signif icant) r = .29 (not signif icant) P >.05 - 135 -TABLE XXVIII RELATIONSHIP BETWEEN SEX AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Length of stay in days Length of stay in days Male (20) Female (10) Male (16) Female (14) 8 10 6 6 4 8 10 5 7 20 7 12 5 12 7 7 10 9 4 8 13 9 4 10 4 9 4 9 9 18 5 9 9 8 10 9 4 10 11 8 9 5 13 6 4 8 19 9 10 8 8 10 5 9 4 7 13 7 6 4 X = 7.45 X = 11.3 X = 6.71 X = 8.75 S = 3.94 S = 4.24 S = 2.52 S = 2.05 t = 2.46 (significant) d. f . = 28 t = 2.44 (signif icant) P .05 - 136 -TABLE XXIX RELATIONSHIP BETWEEN SMOKING HABITS AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 > GROUP INSTRUCTION N=30 Length of stay in days Length of stay in days Heavy-smoker Non-smoker Heavy-smoker Non-smoker (N=16) (N=12) (N=14) (N=13) 5 10 5 4 6 8 11 4 7 13 10 4 4 8 5 4 18 6 9 8 9 4 10 13 5 10 10 8 4 5 7 7 9 4 10 9 9 19 9 6 4 7 9 10 12 4 8 8 6 4 13 - 12 10 8. X = 8.19 X = 8.55 X = 8.08 X = 7.21 S = 3.82 S = 4.44 S = 2.36 S = 3.07 t = .22 (not signif icant) t = .81 (not signif icant) d. f . =25 P > .05 - 137 -TABLE XXX RELATIONSHIP BETWEEN WEIGHT AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N=30 GROUP INSTRUCTION N=30 Length of stay in days Length of stay in days Over- Average-weight weight (N=10) (N=5) Under-weight (N=15) Over-weight (N=12) Average- Under -weight weight (N=6) (N=12) 6 13 5 9 8 7 10 4 8 4 • 10 5 7 4 18 11 9 5 9 10 9 10 4 10 19 5 5 13 4 4 6 8 7 10 8 4 9 10 8 9 9 9 7 8 4 6 9 13 12 8 9 20 14 4 10 6 12 7 4 8 d.f . SS MS d.f . SS MS Treatment 2 14.73 7.36 Treatment 2 16.92 8.45 Error 27 532.63 19.72 Error 27 203.08 7.52 Frat io = (2, 27) = .37 F ratio = (2, 27) = 1.13 (not signif icant) (not signif icant) P > .05 - 138 -TABLE XXXI RELATIONSHIP BETWEEN TYPE OF INCISION AND LENGTH OF HOSPITAL STAY FOR SUBJECTS RECEIVING INDIVIDUAL AND GROUP INSTRUCTION INDIVIDUAL INSTRUCTION N = 30 GROUP INSTRUCTION N = 30 Length of stay in days Length of stay in days Upper abdominal Lower abdominal Upper abdominal Lower abdominal incision (N=20) incision (N=10) incision (N=22) incision (N=8) 8 4 6 4 10 7 12 7 10 5 7 4 13 4 8 4 8 4 10 4 20 4 6 5 12 6 9 5 9 8 9 4 9 5 9 • 9 4 10 19 8 9 7 9 13 18 8 13 10 8 10 7 9 10 10 6 11 5 7 - 9 8 X = 10.6 X = 5.1 X = 8 .91 X = 4.63 S = 4.15 S = 1.45 S = 1 .8 S = 1.06 t = 4.04 (significant at a l l t = 6 .31 (significant at a l l known levels) known levels) d. f . = 28 P 4. . 05 - 139 -TABLE XXXII COMPARISON OF SUBJECTS RECEIVING INDIVIDUAL AND AND GROUP INSTRUCTION BY TYPE OF SURGERY AND BY SEX INDIVIDUAL INSTRUCTION GROUP INSTRUCTION Type of Surgery Male Female Total Male Female Total Hernia Repair Inguinal 8 0 8 7 0 7 Hiatus 0 1 1 1 2 3 Umbilical 1 0 1 1 0 1 Incisional 1 0 1 0 0 0 Ventral 0 1 1 0 0 0 Cholecystectomy 4 6 10 4 8 12 Gastric Surgery 3 1 4 2 3 5 Bowel Surgery 2 1 3 0 0 0 Kidney Surgery 1 0 1 0 1 1 Appendectomy 0 0 0 1 0 1 T o t a l 20 10 30 16 14 30 APPENDIX D Canadian Average Weights for Height and Age - 140 -- 141 -T A B L E XXXIII WOM.FN C A N A D I A N A V E R A G E WEIGHTS FOR HEIGHT A N D A G E TTUiMCN j | n o r J j n o r y indoor clothing, without shoea) Height In Feet - Inches 15 yeors 16-17 yeors 18-19 yoors 20-24 yeors 25-29 yeors 30-34 years 35-44 y e o r » 45-54 yeors 55-64 yeors 65 yooro end O V M 4* 8" 96 105 100 106 110 115 126 130 134 120 9 " 99 107 103 108 112 117 127 132 137 124 10" 101 110 107 U l 114 119 128 134 139 123 11" 104 112 110 113 117 122 130 137 141 132 5 ' 0" 107 115 114 116 119 124 131 139 144 136 1" 109 117 118 118 122 126 133 142 146 140 2" 112 120 121 121 124 129 134 144 143 144 3 " 115 122 125 123 127 131 135 146 151 143 4" 117 125 129 126' 129 133 137 149 153 152 5" 120 127 132 128 132 136 133 151 155 157 6 " 123 130 136 131 134~ 138 140 153 153 161 7" 126 132 140 133 137 140 141 156 160 165 8" 123 135 143 136 139 143 143 .158 162 169 9 " 131 137 147 138 141 145 144 160 165 173 l O - 134 140 151 141 144 147 145 163 167 177 136 142 154 143 146 150 147 165 169 ' 181 TABLE XXXIV MEN C A N A D I A N A V E R A G E WEIGHTS FOR H E I G H T A N D A C S H.lght in Feet - Inches 15 years 16-17 years 18-19 years 20-24 yeors 25-29 years 30-34 years 35-44 years 45-54 years 55-64 years 65 years ood over 4" 11" 92 99 116 121 128 134 135 127 133 126 5* 0" 97 103 119 124 132 138 139 132 141 130 1" 102 . 108 122 127 135 141 142 136 144 135 2" 106 113 125 131 139 145 146 141 148 140 3 " 111 118 128 134 142 148 150 146 151 144 4" 116 122 131 138 146 152 153 150 154 149 5 " 121 127 134 142 149 156 157 155 .157 154' 6" 125 132 133 145 153 159 ! 6 J - 160 160 153 7" 130 136 141 149 156 163 "164 165 163 163 8" 135 141 144 . 152 160 166 168 169 166 167 9 " 139 146 147 156 163 170 172 174 169 172 10" 144 151 150 159 167 173 175 179 172 177 11" 148 155 153 163 170 177 17?. 183 176 181 6' 0" 153 160 156 166 174 181 183 188 v 179 186 1" 158 165 160 170 177 184 ' 186 193 182 191 2" 163 169 163 173 181 138 190 197 185 195 3" 167 174 166 177 184 191 194 202 188 200 "Dietary Standards For Canada", Canadian Bu l le t in on Nut r i t ion , March, 1964, p.76. 

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