Implementation of Pre-Operative Education on Deep Breathing Exercise

By NG Tsz Fung Jimi, RN, BSc(Hons), 22/F


Pre-operative education is the one of the key elements in the whole pre-operative care stage, it takes a significant role which helps promoting recovery by enhancing the awareness of post-operative needs and complications. The education is mainly driven by the nurses which involves the information related to the surgery and the nursing care after operation.

Pulmonary complications are commonly observed during post-operative stage, including atelectasis and sputum retention, and can be minimized by promoting pulmonary function and recovery.

Deep Breathing Exercise (DBE) is part of the pre-operative education which focused on promoting pulmonary conditions. It reduces post-operative pulmonary complications, and hence decreasing the recovery time, length of stay. Morbidity and mortality. Therefore, an effective DBE patient education is essential. It includes:

  • Correct DBE concepts and knowledge
  • Promotion of patient autonomy to improve patient experience
  • Discussion of DBE benefits to enhance patient engagement
  • Return demonstration to ensure proper technique
  • Documentation of patients’ progress and evaluation

Purpose and Problem Statement

In clinical setting, the compliance and competency of DBE are inadequate due to three main factors, including:

  1. Nursing workflows (lack of protocol and processes)
  2. Timing of education (preoperatively vs. postoperatively)
  3. Patient readiness for learning (not engaged as stakeholder)

These elements can directly influence patient experience and safety due to insufficient patient education of DBE. Therefore, this project aims at engaging with patients at pre-operative stage for establishing the concept of DBE and strengthening the importance of performing DBE. Standardization and documentation for follow up the compliance and competency of DBE are significant for making improvement during the whole patient journey.

Implementation Plan

Incentive Spirometer were provided to patients who admitted for major and complicated abdominal surgeries. The whole education regimen of DBE by using incentive spirometer were established during the hospitalization by frontline nurses to patients. Verbal and visual reminder were given to them as for promoting the compliance and competency of DBE. Patients' performance were documented and follow up by continuous monitoring from post-operation day 1 to day 3.


Both compliance and competency of DBE showed remarkable improvement after implementation. Four key areas were measured and compared between pre-data and post-data. (N=20)

After the implementation:

1 - Number of patients received DBE education during the hospitalization

  • Increased from 20% to 75%, those at pre-operative period

2 - Frequency of performing DBE

  • Increased from 10% to 80% for those performed ≥5times/day

3 - Frequency of nurses to remind performing DBE

  • Showed the DBE education and reminders from nurses can promote patients' autonomy

4 - Correct performance of DBE

  • Increased from 45% to 90%

Recommendations and Next Steps

There is no doubt that providing DBE education at pre-operative stage improves patient outcome and safety. Limitation is unavoidable, especially the time for education, as a result, extension of care is essential. For those patients not received education before operation will be documented and follow up after surgery. Further promotion of benefits for performing DBE is required. In current situation, nurses still require prescription from physicians for DBE with incentive spirometer. Therefore, patient could be skipped the education if there is no related prescription. Standardization of DBE into major/complication surgery care is recommended. Besides, pre-operative care nurse educator is necessary, as frontline nurses are usually incapable spend plenty of time to discuss with patients upon their routine nursing tasks.

Therefore, as short term goals, integration of DBE education with both pre-operative and post-operative care are recommended and to extend to all major/complicated surgical cases. A step further, as long term goals, creating user-friendly education tools, such as pamphlets and video would help increased awareness of performing DBE. Coordination with physiotherapist for education is also beyond doubt.