Contraception, more commonly known as birth control, refers to any number of methods or procedures used to prevent pregnancy and sexually transmitted infections (STIs). Women and men have used methods of birth control since ancient times. This includes withdrawal and forms of abortion. Today, there are many methods and procedures at women’s and men’s disposal that prevent pregnancy and the risk of contracting an STI. When choosing a contraceptive method, women and men must discuss all possibilities regarding their sexual health. Some of the most effective methods are sterilization and the use of intrauterine devices; followed by hormone replacement methods such as injections, medicated rings, and patches; less effective methods of contraception include condoms and other barrier methods; last, “pulling-out” or withdrawing is the least effective method. Specifically, I will discuss the female condom, transcervical sterilization, abstinence, and the contraceptive patch. For each method of contraception, I will discuss its history, effectiveness, convenience, side-effects, and cost.

Created as an alternative to the traditional male condom, the Female condom is a female-initiated form of contraception aimed to prevent pregnancy and reduce sexually transmitted infections, STIs. Currently, there are two versions of the female condom on the market; the original female condom and FC2. The original female condom, approved in 1993, is a polyurethane sheath with rings on either end. Either the female or the male inserts the closed end so it covers the cervix and the other, open, end covers the vulva. Though this condom allowed intercourse for those with latex allergies, the noises produced caused some discomfort for both partners. Consequently, researchers created the FC2 in 2009. FC2’s material is thinner, the rings are softer, and is less noisy overall. Since this form of contraception is female-initiated, the female can insert the condom up to 8 hours before intercourse. Per Hoffman, Mantell, Exner, & Stein (2004), “more than 90 developing countries have introduced the method through public distribution, social marketing campaigns or commercial outlets” (p. 120). Funding and support for this project came from public and private funders, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the manufacturers of the female condom. Accordingly, several countries that had high STI rates such as South Africa, Brazil, Ghana, and Zimbabwe, showed increased female condom when the government promoted and distributed the product.

In Alabama, 1,159 STD clinic clients received a promotional package for the female condom. Nurses supervised these women while they practiced inserting the condom. After proving they could properly insert the condom, nurses gave the women take-home materials. After 6 months, the episodes of condom-protected intercourse went from 40% to 50%. Admittedly, this study did not have a control group where the women did not receive the materials. However, the increase of protected intercourse over a six-month period proves that the female condom was influential for couples actively using protective measures.

One barrier to continued use of female condoms is the price. It costs roughly 60 cents to produce the female condom whereas the male condom costs less than 4 cents. Some brands have the female condom priced at around $4 a piece; certain brands of male condoms sell several in a pack for the same price. This price difference is why most sexual health organizations distribute male condoms more widely than female condoms. Another barrier is the ease of use. Some women are not comfortable enough insert the condom and others do not insert the condom properly. The text, “

Exploring the Dimensions of Human Sexuality

” distinguishes between perfect use and typical use. Clinicians determined these measures by looking at the number of women out of 100 who will become pregnant within a year of using the contraceptive. Perfect use is the ability of the method to prevent pregnancy through consistent and correct use, often by or under the supervision of a professional. Typical use is the ability of the method to prevent pregnancy when the individual uses the method at home, unmonitored. Perfect use of the female condom is 95% effective in preventing a pregnancy. In contrast, the typical use is lower, at only 79% effectiveness.

Sterilization is a form of birth control that renders a person biologically incapable of producing offspring. Both men and women can choose to become sterilize; however, individuals age 35 and older usually undergo the procedure more than younger individuals. This method is highly effective. According to

Exploring the Dimensions of Human Sexuality

, only 1 woman out of every 1000 sterilized women become pregnant and only 1 in every 2000 sterilized men cause a pregnancy. This discrepancy is often because those individuals fail to go back to their physician for a follow-up exam to make sure that the procedure was successful. Generally, sterilization is permanent and irreversible.

Two forms of sterilization for women are the Essure and Adiana transcervical systems. Per Palmer & Greenbert (2009), “a microinsert is placed into the interstitial portion of each fallopian tube under hysteroscopic guidance” (p. 85). For Essure, contains 3 to 8 (at the most 18) coiled stainless steel rings, polyethylene terephthalate (PET), and nickel-titanium (nitinol). PET fibers are known to cause an ingrowth of tissue into medical devices because surgeons use PET fibers when they place stents for procedures such as arterial grafts. First, a surgeon places the coils in the proximal fallopian tube. Then, the surgeon expands the device and anchors it within the tube. PET fibers begin to stimulate a benign tissue response and within several weeks, fibrotic growths cause tubal occlusions. Afterward, women who had Essure placements must confirm the placement after 12 weeks by their physician. Doctors suggest using backup contraception until they confirm the proper placement. “Combined data from the phase II and pivotal trials demonstrate no pregnancies in 643 study participants who contributed 29,357 women-months of follow-up, with an average surveillance time of 52.9 and 42.5 months, respectively” (Palmer & Greenbert, 2009, pp. 86-87). Though no pregnancies occurred in the Palmer and Greenbert study; from 1997 through 2004, 37 users worldwide reported their pregnancy to the manufacturer.

Adiana sterilization involves lesioning the lining of the fallopian tubes followed by insertion of a nonabsorbable biocompatible silicone elastomer matrix. As with the Essure placement, over several weeks, fibrotic growths cause occlusions in the fallopian tubes. The women must use other forms of contraception until the doctor confirms placement after 3 months. From 1998 to 2001, there were no major adverse events reported from the trials of Essure Although patients mentioned perforations in 2.8% of the cases; the surgeon was able to fix the issue.

For Adiana, the only significant complications were cases of hyponatremia. The doctor gave these women a diuretic which relieved the symptoms. Removal of Essure and Adiana requires a skilled surgeon should the woman want the devices removed. Women must make sure they want this procedure because reversing a sterilization is costly and the failure rate is high.

People define abstinence in several different ways. Some do not engage in sexual activity at all and others describe how they limit their sexual activities. Abstinence proves to be the only method of contraception and STI prevention that is 100% effective. If you do not engage in sexual activities, you are less likely to get pregnant and contract an STI. Per

Exploring the Dimensions of Human Sexuality,

the only government sanctioned method of reducing the pregnancy and STI rates of teens is Abstinence only until marriage. The government spent over $1.7 billion on sexuality education. However, the programs seem to ignore the effectiveness of other forms of contraception.

The text also mentions that teens often sign virginity pledges. Results show that those who signed the pledges were just as likely to engage in sexual acts as those who did not sign the agreements. Additionally, those who signed the pledges were less likely to use other forms of contraception, less likely to get tested for STIs, and may have the infections for longer than those who did not sign the pledges.

Only one abstinence-only program shows some progress. This program delays sexual activity “until a later time in life when the adolescent is more prepared to handle the consequences” (Greenberg, Bruess, & Oswalt, 2017, p. 193) of engaging in intercourse. Even though abstinence is the least costly and easiest form of contraception to use, it is difficult to practice consistently due to temptation.

Ortho Evraâ„¢, the first contraceptive patch, became available in the United States in 2003. The patch releases a steady dose of estrogen and progestin through the skin. Though the patch holds enough hormone for 9 days, clinicians suggest the user only wear the patch for 7 days. Generally, the user wears the patch for 3 weeks followed by a patch-free week. This patch free week is so menstruation can occur. Per

Exploring the Dimensions of Human Sexuality

, the patch is equally effective as oral contraceptives. It has a 99.7% effectiveness when used perfectly and 91% for typical use. Though the patch prevents pregnancy, there are some disadvantages that comes with use.

Clinicians recommend that the patient uses another method if she weighs more than 198 pounds. Some patients even experience some headaches, nausea, and skin reactions. Some individuals report fears that the effects of heat and vasodilation will increase hormonal responses for those who wear the patch. However, a study done by Abrams, et al. (2001) states that Ortho Evraâ„¢ delivers continuous concentrations of hormones even under conditions of heat, humidity, and exercise. The mean serum concentrations of the hormones were unchanged during the study. However, there were cases where serum levels showed increased concentrations of hormone after a placing a new patch on the skin. For the first two days, of which the woman exercised, tests showed elevated serum levels. However, the levels dropped to typical concentrations for the remaining 5 days of patch use.

The Ortho Evraâ„¢ patch costs around $40 a month depending upon the doctor’s prescription. The woman must also undergo a physical examination to receive the prescription. Health insurance companies usually cover these expenses. Users can place the Ortho Evraâ„¢ patch on the lower abdomen, upper arm, buttocks, or the upper torso. It is ill-advised to place the patch on or near the breasts. The patch offers no protection against STIs so it is wise to use other forms of contraception in addition to the patch.

References

Abrams, L. S., Skee, D. M., Natarajan, J., Wong, F. A., Leese, P. T., Creasy, G. W., & Shangold, M. M. (2001). Pharmacokinetics of Norelgestromin and Ethinyl Estradiol Delivered by a Contraceptive Patch (Ortho Evraâ„¢/Evraâ„¢) under Conditions of Heat, Humidity, and Exercise.

The Journal of Clinical Pharmacology, 41

(12), 1301-1309. doi:10.1177/00912700122012887

Delavande, A. (2008, July 23). PILL, PATCH, OR SHOT? SUBJECTIVE EXPECTATIONS AND BIRTH CONTROL CHOICE.

International Economic Review, 49

(3), 999-1042. doi:10.1111/j.1468-2354.2008.00504.x

Greenberg, J. S., Bruess, C. E., & Oswalt, S. B. (2017). Contraception. In

EXPLORING THE DIMENSIONS OF HUMAN SEXUALITY

(6 ed., pp. 190-221). Jones & Bartlett Learning.

Hoffman, S., Mantell, J. E., Exner, T., & Stein, Z. (2004, October). The Future of the Female Condom.

International Perspectives on Sexual and Reproductive Health, 30

(3), 139-45. doi:10.1111/j.1931-2393.2004.tb00200.x

Landry, D. J., Kaeser, L., & Richards, C. L. (1999). Abstinence Promotion and the Provision Of Information About Contraception in Public School District Sexuality Education Policies.

Family Planning Perspectives, 31

(6), 280-286. Retrieved February 2017

Mosher, W. D., Martinez, G. M., Chandra, A., Abma, J. C., & Wilson, S. J. (2004).

Use of Contraception and Use of Family Planning Services in the United States: 1982-2002.

Factsheet, Centers for Disease Control and Prevention, Division of Vital Statistics. Retrieved February 2017

Palmer, S. N., & Greenberg, J. A. (2009, February). Transcervical sterilization: A comparison of Essure permanent birth control system and Adiana permanent contraception system.

Reviews in obstetrics and gynecology, 2

(2), 84-92. Retrieved February 2017

This assignment will examine the process and methods used when gathering empirical evidence, for a chosen based care issue, using different search strategies and medical databases. An appraisal and discussion of the chosen evidence will also be made, identifying how the evidence was gathered and its relevance to the chosen based care issue. The process of collecting such evidence and the importance of its use will be reflectedupon using a specific reflective model.

The practice based care issue which has been chosen is ‘prevention of pressure ulcers’. A pressure ulcer is an area of localised damage to the skin and underlying tissue (EPUAP, 2009) which develops when there is persisting pressure on a bony site, obstructing healthycapillary flow , leading to tissue necrosis (Lyder, 2003).The rationale for selecting this type of research is due to the high prevalence rate of pressure ulcer among patients and the current lack of knowledge concerning guidelines of pressure ulcer prevention (Moore & Price, 2004). I am very interested in this topic and feel a deeper knowledge of pressure ulcer development and risk assessment tools will enable me to provide better clinical practice. According to Davies (2008) health care professionals are striving constantly to improve and develop standards of care which evolves from the integration of research evidence, clinical expertise and patient needs and values (Institute of Medicine, 2001),this is also known as evidence-based practice.

The reflective model that I will be using is

Rolfe et al

(2001) ‘what’ model which composes of three main areas, what? So what? Now what? This model aims to identify the following; what was I trying to achieve? What is my new knowledge of understanding? What information is needed to face a similar situation again? Ichose this particular model compared to John’s model of reflection (1994) as I found it the easiest model for organisation and meaning to the process of reflection.

.Reflection involves accessing previous experience to help in developing tacit and intuitive knowledge (Johnsand Freshwater, 2005) and the main principles of reflection include becoming mindful, understanding and learning from experience. Reflection facilitates an evaluation of one’s own practice, both as individuals and with their teams (Sines, Saunders & Burford, 2013). It is vital that Nurses reflect and practice reflectively as it allows them to learn from experience and make better future judgement, becoming critical practitioners and facilitating excellent patient care.

The critique model I will be using for the critical appraisal and discussion is the Critical Appraisal Skills Program (CASP) as it is a clear tool which identifies the worth of the articles I have found (CASP, 2013).

Critical Appraisal

After researching for relevant articles, I decided to choose three of the most relevant articles to critically appraise. Each of these three articles involves a study evaluating the effectiveness of prevention strategies for the development of pressure ulcers.

The first single blind randomised control study by Webster et al (2011) aimed to evaluate the effectiveness of two pressure-ulcer screening tools against clinical judgement in preventing pressure ulcers. This study had a very clear and focused objective which stimulated the reader to continue reading due to the study avoiding the use of jargon or buzz words (Carr, 2001). This was an experimental and correlation study showing the link between two factors with the aim of producing quantative results. 1231 patients were randomly allocated to either a water low or ramstadius screeningtool or to a clinical judgement group. Randomised Control Trials (RCT) are comparative studies with an intervention group and a control group; the assignment of the subject is assigned through randomisation(Melnick & Everitt, 2008). The advantages of using RCT are that it removes potential of bias in the allocation of participants and that randomisation tends to produce comparable groups; that is, measured as well as unknown or unmeasured prognostics factors and characteristics at the time of random allocation will be balanced (Friedman, Furberg & Demets, 2010).

The researchers ensured that patients allocated were excluded if their hospital stay was expected to be less than 3 days or if they had been in hospital 24 hours prior to the baseline assessment occurring. This is to allow thorough and regular direct observation of the incidence of hospital acquired pressure ulcers, allowing the researcher to attempt to control the studies validity and reliability (Marshall, 2004).

In a research study it is vital that the researcher ensures that the subjects are aware of the process of the study and have given informed consent. In the case of this study, for pressure ulcer screening and observation, consent was not required. However, signed consent was sought from any patient who developed a pressure injury in order to validate the assigned pressure ulcer through clinical photography. The researchers also obtained institutional ethics approval which included the right to access the patient’s medical record for audit purposes. The incidences of hospital acquired pressure ulcers were similar between all groups.

The authors found no evidence to show that two common pressure ulcers risk assessment tools were superior to clinical judgement to prevent pressure injury. The authors felt that resources associated with the use of these tools might be better spent on careful daily skin inspection and improving management targeted at specific risks. This is supported by the work of Sarabahiand Tiwari (2012) who suggests a regular and rigid schedule of inspection must be followed as part of the patient’s daily routine. Nurses undertaking the trial were more familiar with the Water low scoring system which could have led to contamination in the clinical judgementgroup. The limitation of this study is that they did not use patients from acute settings who could be at risk and therefore cannot use these results as a representation of all hospital settings.

The second randomised controlled study by Nixon et al (2006) aimed to compare whether differences exist between alternating pressure overlays and alternating pressure mattresses in the development of new pressure ulcers. This criterion for this study involved participants aged at least 55 years who had been admitted to vascular, orthopaedic, medical, or care of elderly wards, and had limited mobility.

The methodology used for this study was pragmatic, open, multicentre and randomised controlled trial. An open label study is where the investigator and experimental units knows which treatment the experimental unit is to receive. Although this type ofstudy is simple and easy to design, it could cause the individual to favour the type of treatment, leading to possible bias (Ambrosisus, 2007). A multicentre method involves the study being conducted by several institutions. An advantage to conducting a multicenter is that it increases the number of patients available to participate (Bhandari & Joensson, 2011), which in the this trial is a large 1972, leading to the findings beinghighly likely to be representative of what would happen in usual clinical practice.

The design of this study involved patients beingallocated to either an alternating pressure overlay or an alternating pressure mattress, within 24 hours of hospital admission, with the expected length of stay of at least seven days. Clinical research nurses assessed skin status twice weekly for 30 days and then once a week up to 60 days for the development of pressure ulcers. A limitation of this study is the lack of blinded outcome assessment due to difficulty in disguising or masking the mattresses, however, according to Khan, Kunz, Kleijen & Antes (2011) only few observational studies manage to implement appropriate measures to achieve blinding. The researcher tried to combat this through independent skin assessments which were taken by the Nurses to avoid any bias.Ethical approval for this study was approved by theNorth West multicentre research ethics committee and local ethics committees in order to undertake this research. This study had a clear aim to evaluate the effects on pressure ulcer risk and was able to undertake the study with fairly low rates of ulcer incidence, meaning the patients were subjected to minimal harm.The most important issue arising in the ethical review of scientific research involves preventing human participants, is risk of harm (Smith & Waddington, 2013)therefore it was extremely important that the researchers were able to conduct this study with low incidence rates.

The results of this study were that the patients allocated to either an alternating pressure overlay or alternating pressure mattress that developed a new pressure ulcer of grade 2 or worse did not differ, highlighting the need for other preventive measures.

The final study by Moore et al (2011) aimed to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens. The researchers aim is very clear, evaluating the effectiveness of positioning patients 3 hourly and 6hourly at night time. The methodology used was a pragmatic, multi-centre, open label, prospective and cluster-randomised controlled trial, similar to the study above, the findings are highly likely to be representative of what would happen in usual clinical practice due to a multicentre approach being commonly accepted as providing a more representative population (Luchetti &Amadio, 2008). Cluster randomised control trial involves randomizing professionals so it is much easier to keep the intervention separate from the control groups but methodological, statistical and ethical issues must be taken into account in making sense of cluster trials(Gilbody & Bower, 2010). This study did indeed ensure that ethical approval was received by participants before the study commenced.

The results obtained through the research were that repositioning patients with a pressure ulcer every three hours at night, using the 30 degree tilt, reduces the risk of pressure ulcers compared with usual care which issupported by the recommendations of the International pressure ulcer prevention guidelines (2009). Arguably, the research is well written with a good amount of supporting literature, stating clearly the incidence of pressure ulcers with a good rationale for the studies aim. This study included results of other similar researchers who have found similar results of repositioning, giving scope for further research such asDefloor et al (2005). The limitation of this study is that the target of 398 participants was hard to find which caused the variance in the size of the clusters to be different, which could have had a major effect on the research gathered. Another limitation is that most participants were 80 years or older which means it cannot be a representative of most patients, as expected.

Reflection

Using the Rolfe et al (2001) reflective model, I will evaluate the actions in undertaking my searches and what I found. As mentioned above, the stages of the reflective model includes what? So what? Now What?

The first stage (what?) involved the process of searching for my articles in relation to the subject issue‘pressure ulcer prevention’. Using the databases,Pubmed, Scopus and JSTOR I searched for articles using key words such as, prevention, pressure ulcer, pressure sore and risk assessment. In order to limit the amount of results gathered I used the Boolean operators ‘and’ and ‘or’ as well as advanced searches such a ‘UK based’ and ‘No older than 2005’; ensuring a realistic amount of hits were gathered, relevant to the subject issue. In order to identify relevant articles, I read through the titles and abstracts, as this gave me an idea of how relevant the articles were. Once I read through a few studies, I was able to choose 3 studies to critically evaluate.

The second stage (So what?) involved identifying the difficulties which I encountered when conducting the search. I found the searching quite challenging as many of the results either came back as a large amount of hits or a small number of hits based around irrelevant research to my subject. Using keywords and re wording phrases such as ‘pressure sores’ instead of ‘pressure ulcers’ enabled me to widen my search.

The final stage (Now what?) involved reflecting on the search which I had undertaken as well as the results obtained. I had to conduct many different searches and keywords to find effective results. The problem I encountered was that many results obtained were regarding wound care and not prevention; if I was to repeat this search again I would ensure I put ‘NOT wound care’. I feel further exploration of medical databases would be beneficial for future research to give me a better understanding of search terms and criterion available.

Prior to carrying out this assignment, I was certain that risk assessment tools played a major part in the role of pressure sore prevention. However, risk assessments such as water low, have been criticised due to its poor validity, particularly for the tool to underestimate the numbers at risk (Pancorbo & Fernandez, 2006). Thestudies which I have critically evaluated have made it clear that observation and repositioning is key to pressure sore prevention. As identified by Guyatt et al, (2000) Nurses do not feel sufficiently competent to be able to appraise research findings because they lack the necessary understanding of information retrieval techniques, research design and data analysis and therefore it is important that Nurses are educated in pressure sore management, for clinical practice to be effective.

This assignment has expressed the importance of evidence based practice for effective clinical practice,although contradictory findings from different sources and a lack of critical appraisal skills can make interpretation of evidence difficult.

It has taught me the value of observation when caring for patients and made me become mindful of reading and evaluating research to learn and improve my clinical practice. I am aware that repositioning and skin integrity checks are a major pressure ulcer prevention and that risk factors such an nutrition also need to be monitored closely, I feel I will confidently use the knowledge I have obtained when in practice.

This assignment has put into perspective the importance of identifying all factors when caring for a patient and aiming to prevent pressure sores. For future development I would like to do further research on methodology as I believe this will help me to evaluatethe studies in much more depth, especially seeing ascertain study methodological designs are likely to be more reliable compared to others.

Conclusion

In conclusion, this essay demonstrates an effective search strategy for research studies on ‘preventing pressure ulcers’ which have each been critically appraised.

A reflection on the process of the research was carried out using Rolfe model of reflection (2001) highlighting learning outcomes as well as encouraging me to exploreimprovements for my future practice and search strategies.

Introduction

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).

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.

Description

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.

Feelings

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.

Evaluation

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.

Analysis

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.

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.

Conclusion

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.

Action Plan

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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• The ‘So What?’ Model Of Reflection