Reflection within Healthcare, has been outlined as the active process of reviewing, analysing, and evaluating experiences and then interpreting or assessing them (Atkins and Murphy,1994). Reflection allows healthcare professionals to draw upon theoretical ideas or previous learning, in order to inform upcoming actions(Reid,1993). Reflective practice ensures that healthcare professionals are constantly learning and improving their practice(Ukessays,2019). This improves patient outcomes and the quality of the service provided. There two main types of reflection used by Healthcare professionals: ‘reflection-in-action’ and ‘reflection-on-action’. Reflection-in-action is described as a ‘action present’ it is a primary response, where it involves reflecting on the event whilst it can still benefit the situation rather than reflecting on how you would do things differently if it occurred again(Schon,1983).Alternatively, Schon describes ‘reflection-on-action’ as how practice can be elaborated(changed) after an incident has occurred(Schon, 1983). It is vital for cardiac physiologist to reflect-in-action and on-action during situations and identify one’s actions and results from reflection. This allows health professionals to value practice and make sense of challenging and difficult situations (Chapman et al,2008) and reflect on positive experiences. Which improves patient care and helps increase and better clinical knowledge and skills(Jayatilleke,2013).
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There are various types of reflective frameworks, that supports a structured process to guide the act of reflection. They all have common aims: to get the best results from learning, each individual model of reflection targets is to unpick learning and make relations between the ‘doing’ and the ‘thinking’(Cambridge-community,2019). Kolb’s Learning Cycle (1984) consists of a four-stage reflective model. It highlights reflective practice as a tool to gain conclusions and perceptions from an individual’s experience at work. Rolfe et al.’s (2001) framework is expressed as the most helpful model for descriptive reflective writing. It consists of three levels, such as: what? so what? and now what? that support more of a reflective thought at each stage, however its structure is considered to be one of the simplest models which causes it to have an uncertain sequence. The Gibbs cycle (1998) represents a six-stage approach, it implicates learning from past experiences through to conclusions and considerations for future events. The principles are similar to the Kolb’s cycle; however, the Gibbs model is further broken down to clear defined sections encouraging practitioners to reflect on their individual thoughts and feelings. The model also has an action plan stage, which aids practioners if the situation was to occur again. Therefore, for this essay, I will be using the Gibbs Reflective cycle as it is more specific and processes analysis to be organised increasing the clarity.
During a morning clinic of performing stress-echo’s, I was responsible for assisting along with my supervisor when a male patient was called into the exercise room from the department waiting area. I started off by introducing myself and confirmed the patient’s details, whilst my supervisor prepared the equipment’s ready to start the test. I then washed my hands and asked the patient if they have been on the treadmill before. I then explained what the procedure will be consisting of “ I am going to need you to remove your top half of clothing off and lay down on the bed and whilst you are doing that I will be attaching electrodes onto your body that will allow us obtain a recording of your heart rhythm and heart rate, whilst doing that my supervisor will be placing a blood pressure cuff”. After the patient had given me consent, I started preparing the skin, using exfoliating gel before I placed the electrodes on the patient chest, in the fourth intercostal space(SCST,2017). After finishing preparations, I explained to the patient that the doctor will take a pre-test scan before they can go onto the treadmill and after the doctor has recorded all base-line images of the heart walls he will then go on to the treadmill. I also informed the patient that he will be exercising for a minimum of nine minutes, with an aim to reach their target heart rate. I also clarified to the patient to be aware that within each stage the treadmill gets faster and steeper and it is important for them to sit back onto the bed as fast as possible when the test has been terminated to record further images of heart after it has been stressed.
As the patient started exercising I was monitoring their heart rate and rhythm which was shown on the ECG screen. During the early stages of the test the patient had a normal heart rate and the ECG indicated normal sinus rhythm. As the stages progressed the patient stated that they started to feel short of breath and slight chest discomfort during this stage I was trying to record rhythm to see if there were any significant ST changes or any sinus bradycardia/tachycardia abnormalities. However, there was a lot of artefact showing on the ECG. I then noticed that half of the electrodes were falling off, I then tried replacing the chest stickers with a new set of electrodes and they were also not staying on patient chest. I released the intensity of exercise caused the patient to sweat which lead to the chest hairs becoming moist causing the chest electrodes to become detached from the chest. I was more focused on getting the procedure done as lunch time was approaching. This caused me to forget to remove the patient’s chest hairs, also my supervisor did not think the patient’s chest hairs were hairy enough to have an effect on the test therefore, my supervisor insisted on beginning the test. Due to the electrodes not sticking I was unable to record the rhythm at the stage the patient started to feel symptoms. I became really nervous and confused on what I should do as I could not obtain a clear enough reading to present to the doctor due to my poor skin preparation as the male patient was very hairy and due lack of concentration and awareness, I forgot to ask for consent to remove some of the chest hairs which if I had removed the hairs it would have avoided a poor recording of the event. The patient had been on the treadmill for about six minutes, I then informed my supervisor and the doctor about the situation and we decided to terminate the test due to patient symptoms, during the recovery period my supervisor told me to reapply a new set of electrodes on the patient chest and there were was not any abnormalities shown, so we dismissed the male patient and I called in the next patient.
Before the incident occurred, I was feeling extremely confident as I correctly skin prepared my previous patients and attached each electrode in their correct positions this caused us to be on track. I was also feeling relaxed as the appointments were going well without any complications, this was because previous patient did not have a hairy chest, so there was not any need to think about collecting the razor from the AECG room. I was used to just using the abrasive finger pads and exfoliating gel during skin preparation, that this patient’s situation was unpredicted. The first thing that I thought that I was not going to produce an accurate report for the doctor, at the time I felt extremely embarrassed and upset by my own inability to notice to remove the chest hairs. I was unsure if not being able to obtain a recording during the event, would affect the test. I was also anxious about the doctor not being able to understand the report which could of lead the patient to be incorrectly diagnosed. I was also upset on how I would be viewed by my supervisor, doctor and the patient who would have expected that I knew the importance of correct skin preparation during a test procedure. Looking back at this, I believe if I was more concentrated and removed the patient chest hairs, that the electrodes would have stayed on which would have minimised the artefacts produced. Nevertheless, I was reassured by the doctor that the echo showed a normal study and he did not see any heart abnormalities, which indicated the symptoms the patient was getting was not caused by their heart. This was fulfilling as the patient left the exercise room feeling content, after speaking to my supervisor I felt more relaxed and realised that feeling nervous is a natural reaction.
A positive outcome to the situation was the echo images did not indicate any heart abnormalities. Another positive was the patient symptoms of chest discomfort and shortness of breath seemed to have faded away during the recovery period. Regardless of not being able to record the rhythm during the stage the patient started to feel symptoms and the embarrassment feeling, I still managed to place a new set of electrodes when the patient stopped exercising. I also addressed the patient well and spoke clearly to motivate the patient whilst they were on the treadmill also managed to complete the test procedure to the patient best ability. Regardless of the poor ECG qualities, overall the test lasted about half an hour to record all the stages and obtain images after the heart had been stressed, this also was another positive as deadlines were achieved.
At the time, showing my nervous and confused expressions to the patient was an unprofessional response to the situation. I feel like that could have made the patient have doubts in my ability. I was liable for making sure that I skin prepare correctly, and, in this case, I let myself, my supervisor and doctor down, because it caused slight signs of uncertainty of why the patient had symptoms during the exercise.
There’s a variety of theories that can be reviewed in order to evaluate the situation that occurred and relate back to the subject of reflection in practice and how health care practitioners practice this routinely.
Experiential learning theory(ELT) implicates learning from an experience(Cherry,2019). It is a holistic theory and highlights experiences, cognition, environmental factors and emotions, which impacts the learning process. Kolb’s (1984) theory works on two levels: consists of a four-stage cycle of learning also four distinct learning styles(Mcleod,2017). Kolb portrayed different ways of grasping experience for example: “Abstract Conceptualisation” the process involves making sense of a situation that has occurred and interpret the event and understanding the relationship between them(Evans,2018). Relating to my practice, my situation was an example of experiential learning, as I had logically analysed the situation and understood the importance of being vigilant and focussed during the procedure, as I noticed that the electrodes were detached and needed replacing to be able to obtain clear recordings. Due to having former patients without a hairy chest whilst skin preparing, when the situation happened it had a major impact on learning as if I had removed the patient’s chest hairs, the electrodes would not have come off and I would have been able to obtain an recording whilst the event was happening, this would of gave the doctor a better understanding of what the cause of the symptoms could of been. ELT also states that “Reflective observation” within this stage it involves the practitioner to take time-out from “doing” by removing themselves from the task and review what has been done (Llevot-Calvet, Bernard-Cavero,2018). However, I did not employ this as when the situation happened at the time I did not reflect on the event, due to the fact I had called in my next patient as soon as the previous patient had been done, as It was a busy clinic and still had more patients to perform the procedure on before clinic closing times.
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Social Learning Theory, indicates that individuals learn from one another through observation, imitation, and modelling(Bandura,1925). The theory is expressed as a link between behaviourist and cognitive learning theories due to the fact it covers attention, memory, and motivation. Bandura adds two ideas: Mediating procedures occur amongst stimuli and responses also behaviour is studied from the environment by a process known as observational learning. Observational Learning states that “people learn by watching others perform the behaviours” (Bhutia,2017). An example of this is watching cardiac physiologist assist in the performance of stress-echo’s as they ensured that they explained clearly and correctly identified patient details and interacted with the patient during the test procedure. Bandura theory is applicable to my practice as I had observed the physiologist interacting with the patient, they ensured the patient understood the procedure. I also observed the cardiac physiologist correctly skin preparing the patient before they went on to the treadmill, it was vital for me to observed before being allowed to assist during stress-echo procedures. Bandura developed modelling processes which includes certain steps such as: Social cognitive theory(attention) which states that “It is important to pay attention for you to be able to learn” (Sincero,2011). However, I did not utilise this theory as I did not pay attention when I was observing how to assist in stress-echo’s as myself and my supervisor was not aware that I had forgot to correctly skin prepare the patient before attaching the electrodes.
Another significant theory is Situated Learning theory (1990), which suggests that learning is unintentional and located within reliable activity, context and culture(Lave&Wenger,1990). Lave and Wenger claim that an individual is more motivated to learn by actively being involved in the learning experience(Clancy,1995). The theory indicates that learning takes place within relationships between people and connects previous knowledge with reliable, informal, and unintended appropriate learning(Stein,1998). Situated Learning theory can be divided into varies categories, for example “learning”. According to Lave, learning happens only “if the learner is placed into a realistic real-life situation” (Clancey,1997). Relating to my practice, my situation was an example of situated learning as I was able to realise the mistakes that I had made when assisting in stress-echo’s. By having previous positive experiences when performing the procedure, when the event occurred it had a major impact on learning as it made me more aware of the importance concentration and correct patient set up. Within Situated Learning theory, Wenger suggests that “Practice groups should share a concern or a passion for something they do and study how to perform it better as they regularly interact(Wenger,2000). However, in my case I did not apply this acquired sense. As I did not speak to other members of staffs during the time the situation occurred, about my worries of not providing the doctor with a full detailed patient report.
Another theory relative to my experience is “Information processing theory” Miller (1920) reviews the mechanisms through witch learning occurs(Miller,1920). Miller, developed the theory and assumed that the mind obtains the stimulus, process it, stores it, locates it and then responds to it(Thadani,2018). The theory approaches a cognitive development of an individual, which deals with the learning and the evaluation of the series of events that occur in one’s mind while obtaining new information(Thadani,2018). Information processing in humans is compared to a computer model, perceptive psychology sees the individual as a processor of information, in an equal way that a computer receives information(Mcleod,2008). Information processing is based on varies statements, for example the theory expresses that “Information made available by the environment is processed by a number of processing systems (e.g. attention,
perception”) (Mcleod,2008). This theory is applicable to my practice as during the early stages of the stress-echo procedure, I was paying attention on the patient’s heart rhythm and heart rate ensuring that there were not any significant changes. I was also aware of my patient capability whilst they were on the treadmill, as I kept on reassuring them if they were able to carry on exercising as the stages progressed. The information processing theory also state that the “information received from the external or internal stimuli is stored in our short-term or long-term memory, and it interacts with previous saved info to create a response, or output” (Encyclopedia,2019). However, this was not applicable to my situation. Although I have previously observed and assisted in stress-echo procedures, I still managed to incorrectly skin prepare my patient by not removing the chest hairs.
In conclusion, I should have been more alert and as soon as I noticed that the electrodes were not staying on, I should have asked for consent from the patient and removed the chest hairs and replaced new electrodes whilst they were still on the treadmill. My experience has educated me on the importance of the ‘Learning’, by realising my mistakes I was able to learn and understand the importance of correct skin preparation. In my opinion I believe I learnt best through situated learning as it states that learning only occurs when ones have been placed in a realistic-real-life situation, without the situation occurring I would not have understood how vital it is to pay attention during the procedure of test and how significance it is to correctly skin prepare patients. Overall, my experience resulted to be a negative, in order from stopping this occurring again I will ensure that I am well concentrated whilst performing the procedure.
If a similar incident occurred again I will ensure that I approach it in a distinctive manner. However, I was not pleased with my ability during the situation which indicated lack of concentration and knowledge towards the patient, my supervisor and doctor. To prevent this from happening again I will guarantee that I am focused at all times and have more determination to improve the care provided to the patient.
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