Carnavelis Decision Making Model - Research Paper Example

CARNAVELI’S DECISION MAKING MODEL of Doris Carnevali’s model of clinical judgment and decision making postulates that an integration of critical thinking is important for effective diagnostic reasoning (Carnevali, 2003, p. 45). The diagnostic role of a nurse is the assessment and evaluation of the patient’s condition and application of theory and practice in prescribing the most effective nursing intervention and therapy for the health condition (Banning, 2008, p. 187). The effectiveness of a nurse’s role is achieved through the assessment of the social, physical, mental, and spiritual and health factors which define the needs of the patient. This paper is based on a clinical case study where the roles of nurses in assessment of the patient and related factors and decision making and practice are discussed. The discussion is based on Carnevali’s model of clinical judgment and decision making which evaluated in terms of its effectiveness and impact on the execution of nursing roles in patient assessment and decision making. Part I The assessment of Jack’s physical, social, mental, spiritual and health care needs will be based on an integration of critical thinking and observation. Wolf (2012, p. 20) explains that the ability of a nurse to identify the needs of the patient during the assessment process is effectively achieved through keen observation and application of higher cognitive processes of thought. Kearney and Penque (2012, p. 32) adds that the legal and ethical standards of nursing and evidence based practice should also be included in trying to identify the needs of the patient. In Jack’s case, his symptoms are used to assess his health care needs. For example his dehydration is identified through the nurse’s observation. This leads to a critical thinking process through which the nurse will make a decision of the nursing intervention and therapy which is relevant for his condition. The significance of Carnevali’s model of clinical judgment and decision making is disclosed in this case because effectiveness in assessment of the health care needs of the patient would only be achieved through observation of his symptoms. Carnival’s model presents the first stage of diagnostic reasoning process as the collection of information and data on the patient and the family (Carnevali, 2003, p. 45). Aitken, Marshall, Elliott and McKinley (2009, p. 38), add that the roles of nurses in patient diagnosis are guided by collection of patient data on the social and cultural aspects and applying them in the prescription of relevant intervention and therapy. Jack for example is affected by social factors such as lack of appropriate support and care from the parents. This is disclosed by the fact that the parents want to leave him in the hospital with a neighbor. Nonetheless, critical thinking and prioritization must be applied in nursing care to ensure that the health care needs of the patient are provided before further assessment achieved. Jack’s dehydration and weakness requires immediate nursing intervention even before a complete analysis of all factors surrounding his condition are ascertained. Huiqin and Thompson (2010, p. 2752) points out that nurses play a critical role in meeting the needs of patients for care with due consideration of the standards of care and maintenance of high standards in practice. However Carnevali’s model of clinical judgment and decision making fails to show emphasis on the role of ethical and evidence based nursing practice. In accordance to Carnaveli’s model of clinical judgment and decision making, the second stage in diagnostic reasoning process is entry into the patient assessment (Carnevali, 2003, p. 45). This includes priority setting. Jack’s health care needs are prioritized by the nurse because of his weak condition and continuous crying. This is the reason why the nurse must prioritize the health care needs of the patient. Sutcliffe (2011, p. 35) emphasizes that the Nursing and Midwifery Council mandates nurses to attend to the health care needs of the patient as top priority. In this regard, Jack is given IV fluids as soon as possible and further fed and monitored. This reflects the roles of nurses for beneficence. Cornock (2011, p. 18) explains that the decision making process of nurses should be guided by the assessment of the patient and the overall obligation of doing what is good for the patent. It is in this regard therefore that the decision that the nurse makes for feeding and monitoring Jack is focused at what is good for him. The third stage of Carnevali’s model describes data collection through a screening process and the application of a problem oriented approach. The assessment of Jack’s social needs represent the problem which can be achieved through collection of information through evaluating the behavior of his parents and the neighbor in relation to their roles in meeting his needs. Carnevali’s model of clinical judgment and decision making is an effective guideline on assessment of the social needs of the patient. This is due to the fact that Carnevali’s model describes entry into the patient assessment situation in the light of laying strategies for the collection of data (Carnevali, 2003, p. 45). In this case, the collection of data will involve interviewing the parents and the neighbor with a view of gathering data on the social needs of the patient. The assertion by Jack’s mother that he is irritable reflects that his social needs are not being met adequately. In accordance to Park (2012, p. 139), the diagnostic role of a nurse is achieved through close observation and evaluation of the needs of the patient. The relevance of Carnevali’s model of clinical judgment and decision making is nursing care is reflected by its fourth stage of diagnostic reasoning process which postulates selection of the pivotal cue clusters. This includes determining the patient needs which requires to be met with urgency (Carnevali, 2003, p. 45). Jack’s present situation reflects limited affection and love from his parents. It is only after being offered a bed within Jack’s cubicle that his mother decides to stay. Jack needs to be fed because of his weak condition. This need is more urgent among the cue clusters and is attended to immediately through the intervention of the nurse. When the social needs of patients are limited by less caring relatives or friends, nurses are mandated to prescribe an effective intervention for meeting needs (Pearcey, 2008, p. 1320). The case of Jack calls for a decision by the nurse, as based on assessment of the present situation, to involve the parents in the treatment process. For example the roles that the parents have to play for the well being of the patient must be articulated clearly to them to and ensuring compliance. The assessment of the patient’s needs forms a basis for a nurse’s decisions on the legality of parents’ behavior (Toren and Wagner, 2010, p. 393). The nursing role in Jack’s case involves the assessment of the parents’ contribution to his current condition. Observation of the mother’s anxiety and defensive behavior requires critical thinking and proper assessment of the situation for decision making. The many bruises on Jack’s thighs and buttocks should be the motivation of the nurse’s decision making. Therefore the nurse must ensure that the parents take legal and ethical responsibility if they played as role in bruising the patient. It is in this regard that the postulates of Carnevali’s model of clinical judgment and decision making are important. This is reflected by proper assessment of the situation to avoid misjudgment. Pretz and Folse (2011, p. 2878) explains that in the collection of information about a patient, it is necessary that nurses achieve proper assessment that is supported by critical thinking and cognitive reasoning. This is because wrong information is often provided by the patient’s relatives. Comfort is a significant physical need of a patient which nurses should ensure that it is met (Saintsing, Gibson and Pennington, 2011, p. 354). The general physical state of the patient reflects his needs for comfort and general well being. For example, the bruises and nappy rash requires that his positioning on the bed is aimed at ensuring that he is as comfortable as possible. Wilson, Talsma and Martyn (2011, p. 805) explains that in making nursing decisions, potential benefit must be weighed against the harm which would emanate from medical procedures. Furthermore the risk factors in nursing care are adequately provided by Carnevali’s model of clinical judgment and decision making (Carnevali, 2003, p. 45). In this sense, the assessment of the physical needs of the patient is based on the possible risk and benefits which would result from the kind of nursing procedure that the patient is taken through. For example bruising of the patient and the rash are possible avenues of infection. Therefore the nursing decision on medical intervention must ensure that the treatment of the nappy rash and bruises considers the physical needs of the patient for comfort. Jack’s physical needs for comfort are also reflected by the fact that he is irritable and continuously cries. The mental and spiritual needs of the patient include the need to be freed of pain. Carnevali’s model of clinical judgment and decision making contributes significant to the assessment of the mental and spiritual needs of patients and deciding on appropriate nursing intervention. This is revealed by the model’s prescription of the utilization of diagnostic choices to determine the defining characteristics of the patient condition (Carnevali, 2003, p. 45). The characteristics of Jack’s condition involves pain as revealed by his constant crying, bruising and nappy rash. Ryan and Jezewski (2012, p. 131) demonstrates that it is through the relief of a patient’s pain that mental and spiritual needs of being freed from pain are met. Sorensen, Delmar and Pedersen (2011, p. 421) adds that nursing practice must adhere to the rights of pain such as not being subject to unnecessary pain. These rights are postulated within the NMC code of ethics for nursing practice (Goethals, Dierckx de Casterle and Gastmans, 2012, p. 1198). The nurse is therefore mandated to make proper decisions on Jack’s care in regard to the assessment of his pain with a view of reliving his pain. Mccallin and Frankson (2010, p. 319) argues that quality of nursing care is evaluated through the ability of nursing interventions to assess and relief the pain of patients. Part II Carnevali’s model of clinical judgment and decision making is important in the diagnostic reasoning process especially when there is need for selecting a medical situation of greatest importance or urgency (Carnevali, 2003, p. 45). The decision trees within the wars in the case study reflect the role of a nurse in deciding the medical situation which requires to be attended to as a matter of urgency. This is especially demonstrated by the teenagers who are admitted for being involved in a road traffic accident. Silen, Svantesson and Ahlström (2008, p. 160) point out that effective management of a ward is achieved through a nurse’s experience. On the other hand, Hinno, Partanen and Vehviläinen-Julkunen (2012, p. 1584) argue that it is through a holistic view of nursing care that nursing interventions are directed at meeting the standards of care, ethics of practice and patient centered care. The number of beds and their occupancy by both patients and their parents defines the priorities which the leading nurse will give to the patients. These decisions must be guided by close assessment of the needs of each patient before choices are made. For example the assessment of the needs of the newly admitted patients would cause the head nurse to decide on the bed occupancy which may lead to the displacement of some parents. Carnevali’s model of clinical judgment and decision making is disadvantageous in assessment of the wide context within a ward. This is because this model does not emphasize all factors which affect decision making by nurses. For example the legal factors which determine the course of care are not sufficiently highlighted by Carnevali’s model. The fact that the teenagers who were in a road accident were driving a stolen car means that legal factors would come into play. Moreover, the teenagers were driven by their 16 year old colleague. This illustrates that he was legally not allowed to drive because of the requirement for a driver’s license. Traynor, Boland and Buus (2010, p. 1584) reveal that nurses are often faced with dilemmas in deciding between adherence to legal obligations and ethics of practice. As a result a holistic context and view is required in assessing situations in a health care environment so that all factors are considered before executing an intervention. According to Majid, Foo, Luyt, Xue, Yin-Leng, Yun-Ke and Mokhtar (2011, p. 230), competence of registered nurses is proportional to their level of experience. Carnevali’s model of clinical judgment and decision making is important in assessing the competence of the nurse. This is because Carnevali’s model defines the effectiveness of nursing roles in relation to the ability of making proper clinical judgment and diagnosis (Carnevali, 2003, p. 45). The case reveals different levels nurse competence. Silen, Svantesson and Ahlström, 2008, p. 160) explains that the nursing roles may end within a particular clinical condition depending on the level of competence. For example the student nurse in the case may not be able to handle the patients who were involved in the road traffic accident. Therefore the head nurse of the ward through proper assessment of the situation will make decisions related to delegation of nursing duties. For example the registered nurse who is at recovery with a patient will be called into action in management of the condition of the patients who were in an accident. Pavlish, Brown-Saltzman, Hersh, Shirk and Rounkle (2011, p. 386) further illustrates that nurses must make decisions such as patient referral when a higher level of competency is required for a specific condition. The patient in ICU for example will be referred to physicians or surgeons as appropriate. This is achieved through a holistic view of the clinical situation before nursing decisions are reached. Majid, Foo, Luyt, Xue, Yin-Leng, Yun-Ke and Mokhtar (2011, p. 234) says that nurses in charge of a ward are responsible for assessing various clinical conditions as they arise within a wide context. Silen, Svantesson and Ahlström, 2008, p. 162) explains that the decisions of nurses on nursing intervention must be guided by the ethics and legal aspects of practice. Moreover, the nursing standards as provided by the NMC and government policies must be given due consideration in decision making within a health care environment. The concurrent consideration of factors which affect nursing decisions making and proper application of guiding frameworks reveals the role of a wider view of a health care context. Stubbings, Chaboyer and McMurray (2012, p. 1443) argues that proper care must be patient centered and hence the safety, needs and dignity of the patient must be put into consideration regardless of the circumstances under which health care is being provided. Nonetheless, there are exceptions such as emergency care and related issues such as triage which must call the attention of nurses for proper assessment and accuracy in decision making. For example one of the girls who is vomiting and complaining of a severe headache must be attended to regardless of the fact that the circumstances which led to the accident were illegal. Nonetheless, the leading nurse of the ward will be mandated to take legal responsibility by reporting the accident and the circumstances surrounding it to the authorities. The approach that is used by the nurse in charge in the assessment of the situation within the ward must be guided by all aspects of nurse care and practice. Al-Shaer, Hill and Anderson (2011, p. 10) explain that a holistic approach in assessment of medical situations includes the needs of patients, legal and ethical requirements, hospital or organizational policy and the health care obligations of the nurse. Majid, Foo, Luyt, Xue, Yin-Leng, Yun-Ke and Mokhtar (2011, p. 234) add that prioritization must be included in assessment of medical situations depending on the emergency or urgency of a specific condition over another. For example the case study depicts a four year old within the ward with oozing blood because the intravenous cannula was pulled out. In this case, the leading nurse must ensure that a competent nurse takes care of this situation. Effective assessment of the situation will not lead to delegation of the care of the four year old to the student nurse. This case therefore reflects the appropriateness of Carnevali’s model of clinical judgment and decision making in management of emergency situation. This is due to the fact that Carnevali’s model postulates that urgent medical situations are prioritized in health care. However a holistic view in care must consider all factors which affect decisions during the assessment of medical contexts to pave way for making accurate and appropriate decisions. References Aitken, L, Marshall, A, Elliott, R, and McKinley, S 2009, Critical care nurses’ decision making: sedation assessment and management in intensive care, Journal of Clinical Nursing, 18, 1, pp. 36-45 Al-Shaer, D, Hill, P, and Anderson, M 2011, Nurses Knowledge and Attitudes Regarding Pain Assessment and Intervention, MEDSURG Nursing, 20, 1, pp. 7-11 Banning, M 2008, A review of clinical decision making: models and current research, Journal of Clinical Nursing, 17, 2, pp. 187-195 Carnevali D. 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