Introduction
Imogene Kings (1981) theory of Goal Attainment concentrates on how goals of the client are attained through the nurse-client transactions. Nursing goal is to attain, maintain, and regain a healthy state. Goals are developed through the communication and interaction, and within a social system, client goals are achieved- highlighted by mutually set goals among clients and nursing staff. King’s model can be used as a framework for assessing and maintaining a healthy social system that helps clients achieve their stated goals (Parker, 2006). The Theory of Goal Attainment provides an approach to accomplish the goal of access and quality of life.
Goal Attainment Theory of I. M. King and Its Applications
The basis of The Theory of Goal Attainment of Imogene M. King is her philosophical position, which is, rooted in General Systems Theory, which guides the study of organized complexity as whole systems. Constant advances in technology and telecommunication, and vast amount of information overload about the world events makes one’s life complex.
Introduction of the Theorist
After the postsecondary education, Imogene M. King had her diploma nursing from St. John’s Hospital, School of Nursing, St. Louis, Mo. She received her baccalaureate degree in nursing from St. Louis University. Then she achieved her master’s degree in nursing from St. Louis University. She went on to receive Doctor of Education from Teachers Collage, Columbia University, New York and did a Post Doctoral Study in Advanced Statistics, System Research, and Computers (Parker, 2006). She holds 50 Years of Nursing Experience. She has also received Jessie Scott Award for Leadership in 1996 and, Honorary Doctor of Science in 1996 (Parker, 2006).
Introduction of the Theory
A system is defined as a series of functional components connected by communication links exhibiting purposeful goal-directed behavior. Continuous discoveries in technology and telecommunications, and a daily information overload about world events bring complexity to one’s life that is unprecedented in history according to Parker (2006). Instant communication reminds us that we live in an information-processing world of systems. As individuals, we are born, grow, and develop within each nation. Nations made up of world society. A sense of global community can be understood as we view the interactions of individuals and groups with linguistic, ethnic, and religious differences (Parker, 2006).
The commonality in this worldview is the human being who interacts and communicates in his/her small groups within his/her nation’s social systems, that is physical and human environments (Parker, 2006).
King’s Conceptual Systems consists of the following elements with emphasis on Joint Goal Setting by Nurse and Client (Clarke et al, 2009).
Personal: (individual/intrapersonal) Understand the self-perception, own personal growth and development of the client (Parker, 2006).
Interpersonal: (Interactions between 2 or more persons or group). Know the roles, interactions, sources of stress of the client (Parker, 2006).
Social: (Society, school, work, etc.) Understand what affects the client’s decision making, where they find authority and power, their social position (Parker, 2006).
The Concept Development and Validation Process is as follows (Parker, 2006):
Review, analyze, and synthesize research literature related to the concept.
Identify the characteristics or attributes of the concept from the review.
Write a conceptual definition from the attributes or characteristics.
Review literature to select an instrument or develop an instrument.
Design a study to calculate the concept characteristics or attributes.
Decisions are made on selection of the population to be sampled.
Collect data.
Analyze and interpret data.
Write results of findings and conclusions.
State implications for adding to nursing knowledge.
Searching for scientific knowledge in nursing is an ongoing dynamic process of continuous identification, development, and validation of relevant, concepts (King 1975). A concept is an organization of reference points. Concept development is a continuous process in the nursing science movement (King, 1988).
The Theory of Goal Attainment emphasizes on the following issues.
The goal of providing nursing care is to help individuals maintain or regain health (King 1990). Concepts are essential elements of theory. When a theory is derived from a conceptual system, concepts are selected from that system. Theory derived from self, perception, communication, interaction, role, transaction, and decision-making concepts. Self is an individual whose communication, interaction, and decision making in a small and a large groups is influenced by his perception and role. Nurse functions within a healthcare system, a social system made of individuals and group interacting to achieve a health related goal. Unfortunately, in 21 st century cost containment is the primary goal of insurance companies and healthcare administrators. If the nurse and the clients mutually agree upon the goals and means to achieve them, 99 % of the time the goals achievement is possible. Goal attainment represents outcomes. Outcome indicates effective nursing are. Nursing care is a critical element to provide cost effective quality care (Parker, 2006).
What is Informed Nursing Practice? It is to teach nurses to set shared goals with clients and establish a trustworthy monitorable rapport, and to have individual interaction with clients and enhance their participation. It provides steps to identify a common objective and the best means to attain it. It also provides an approach to understand individuals as a whole person, allowing nurses to meet more needs of clients and find underlying troubles by evaluating personal and interpersonal systems. All of the above help nurses to be better by strengthening our relations with clients (King, 2007).
Let us look at Transaction Process Model.
Transaction Process model.png
(From King, I.M. (1981) A theory for nursing systems, concepts and process (p.145) New York: John Wiley & Sons, Inc.)
The Documentation System allows the nurse to watch closely the three different systems in life of the client while doing assessment, diagnosis, plan, and identification of outcomes, implementation, and evaluation (Parker, 2006). It helps to be interactive with the client, and having mutual goals are two important aspects of the theory of goal attainment (Parker, 2006). It allows the mutually selected goals to be more likely met when the nurse and client communicate and work together toward those goals (Parker, 2006).
King developed the Goal Attainment Scale in 1989. It is used to measure goal attainment and may provide client data to plan and implementation of nursing care as an assessment tool. King’s conceptual system and theory is used in nursing education, in nursing practice in the fields of family health, community health, hospital, and also for continuous quality improvement, and in research and as a vision for the future (Parker, 2006).
Application of interacting systems framework is applied to different nursing care situations. Although, it can only serve to guide, rather than prescriptively direct, nursing practice, because it is broad and abstract. It is used to guide nursing practice in large community hospital. It is used to guide nursing practice in large tertiary hospital. Additionally, it is used to guide nursing practice with specific client populations (Parker, 2006).
Concept development within the framework explicates concept more clearly (Parker, 2006), and it may demonstrate hoe other concepts, of interest to nursing can be examined through a “nursing lens (Parker, 2006).” Explication of above assists the development of nursing knowledge by enabling the nurse to understand the application of the concept in a better way within specific practice situation (Parker, 2006). King’s work includes the empathy, health of social system, health of systems, space, transaction, social support, quality of life, power, health, coping, autonomy, and advocacy (Parker, 2006).
An application of midrange theory of goal attainment in practice is for the general application of theory (Parker, 2006). In addition, it is used to explore a particular concept within the context of the Theory of Goal Attainment (Parker, 2006), and explore a particular concept related to the Theory of Goal Attainment (Parker, 2006). Nonclinical nursing situation in practice also have use of application of midrange theory of goal attainment (Parker, 2006). Nursing process and related languages can also benefit from an application of midrange theory of goal attainment. It can be used for development of Standard Nursing Language (SNL) including NANDA Diagnoses, and in nursing interventions, in nursing outcomes, in nursing process as a theory, and in nursing process as a method (Parker, 2006).
Goals for the applications and development of midrange theories within the framework are:
Such theories can be directly applied to nursing situations, whereas a conceptual framework is usually too abstract for such direct application.
Validation of midrange theories, clearly developed within a particular conceptual framework, lends validation to the conceptual framework itself.
Some of the instruments developed using applications of midrange theory of goal attainment are the Health Goal Attainment by King, The Family Needs Assessment Tool by Rawlins, Rawlins, and Horner, Nursing Care Survey by Killeen, and Sieloff-King Assessment of Group Power Within Organization by Sieloff. It is also used for clients across the life span, client systems, phenomena of concern to clients, multicultural applications (Parker, 2006).
The application of the theory of goal attainment is in administration focusing more on commonalities rather than highlighting the differences in settings of nursing specialties, and work. In addition, it is used in health care beyond nursing to improve overall quality and cost efficiency of the health care provided. In managed care and case management settings (King, 2007).
Following recommendations are made for knowledge development related to King’s framework and theory.
The need for evidenced-based nursing practice that is theoretically derived.
The integration of King’s work in evidenced-based nursing practice.
The integration of King’s Concepts within Standardized Nursing Language (SNL).
Analyzing the future impact of managed care, continuous quality improvement, and technology on King’s concept.
Identification, or development and implementation, of relevant instruments.
Clarification of Effective nursing interventions, including identification of relevant nursing implemented concepts based on King’s work.
It is interesting to know how evidence-based practice derived from the theory. Although Florence Nightingale realized the importance of using evidence to guide practice 135 years ago, the field of medicine takes credit for the current trend of evidence-based practice. Despite this, nursing as a discipline continued to evolve in the use of scientific evidence, and evidence-based practice is “the conscientious and judicious use of current best evidence to guide health care decisions (Titler, 1998).”
What is the relationship between King’s concepts, the nursing process, and the SNL? King’s interacting systems framework and midrange Theory of Goal Attainment includes the steps for nursing process. Process applications, assessments, diagnosis, goal setting, actions, based on nurse-client goals, evaluation, and back to process applications… SNL enables the development of midrange theory by building on concepts unique to nursing. Additionally, SNL refines the nursing process (Parker, 2006).
Technology and managed care have an impact on King’s concepts. Changing health-care climate have challenged the existing conceptual framework of nursing requiring adaptation and evolution. In the field of technology, King’s conceptual system provides the structure for health-care informatics, and suggested theoretical basis for nursing informatics: self, role, power, authority, decisions, time, space, communication, interaction with emphasis on goal setting and goal attainment. In the field of managed care, Nursing is increasingly involved with collaboratively developing evidence-based care planning tools and critical pathways, protocols, and guidelines with other disciplines and personal, interpersonal, and social systems need to include an expanded conceptualization of King’s concept of goal-setting (Parker, 2006).
In conclusion, an essential component in the analysis of conceptual frameworks and theories is the consideration of their adequacy (Ellis, 1968). Adequacy depends on the three interrelated characteristics of scope, usefulness, and complexity. Conceptual frameworks are broad in scope and are sufficiently complex to be useful for many situations. Theories on the other hand, are narrower in scope, usually addressing less abstract concepts, and are more specific in terms of the nature and direction of relationship and focus.
Now, let us look at a compromised client scenario (Black & Hawks, 2005).
The first nursing process is nurse meeting the client. The nurse interacts and communicates with the client. Assessment is done by data collection about the client based on relevant concepts.
Mr.Verma is 77 years old, married, were admitted in GSU floor of RN Hospital on 04/01/2011 with a diagnosis of intussusception, and underwent end-to-end anastomosis with prolene mesh done on 04/02/2011. Data collected by addressing following areas (Black & Hawks, 2005).
The client’s perception of the situation is as follows. Client says,” I have undergone surgery for intussusception”. “The wound is healing, and I do not have any other issue.” “I am hurting at surgical site.” “I’m on medicines for high blood pressure for the last 12 years from other hospital” “I have problem with vision in my left eye. I had a surgery in my left eye about 20 years back”. My perceptions of the situation are client underwent end-to-end anastomosis operation on 04/02/2011 for intususception, which he kept untreated for 1 month. Client has problems related to maintenance of health. Client is at risk of infection development. Client has pain at surgical site. Client may develop complications due to high blood pressure in future (Black & Hawks, 2005).
The other information I need to assist this client to achieve health is as under.
HISTORY: Identification details: Mr. Verma is 77yrs married, male, studied up to 9th grade is doing business, a practices Hindu religion, got admitted in GSU floor of RN Hospital on 04/01/2011 with a diagnosis of intususception underwent end-to-end anastomosis with prolene mesh done on 04/02/2011 (Black & Hawks, 2005).
Present History of Illness: Abdominal swelling for 1month with difficult activities and abdominal pain occasionally. He has high blood pressure for 12 years. The swelling remained stable with uncomplicated progress, getting abdominal distension, No history of severe pain but increasing size for the last month not relived after pressing and on taking rest (Black & Hawks, 2005).
Past health history: Client had cataract surgery about 20 years ago, and is on treatment for high blood pressure, no other specific illness (Black & Hawks, 2005).
Family History: Client’s two brothers had inguinal hernias and were operated. One brother underwent three surgeries for hernia (Black & Hawks, 2005).
Client’s socioeconomic status is Low economic status, earning USD 1600 per month. He is non-vegetarian, nonsmoker, and nonalcoholic. He has knowledge of health care facilities. His physical examination revealed that he is alert, conscious, and oriented, slight heavy built, nourishment adequate, with BMI of 27; His vital signs are normal except BP 150/90 mmHg, and general head-to-foot examination reveals normal except for the difficulty in vision of the left eye and abdominal surgical wound, which is healing. Subjective problems are pain at the surgical site, no bowel motion for 3 days. Review of relevant systems reveals following. GI system inspection reveals good wound healing, no sign of infection or redness or swelling. Auscultation reveals normal bowel sounds, palpation reveals pain at site of surgery, abdominal organs are normal, and percussion has no dull sound suggesting fluid collection or ascites (Black & Hawks, 2005).
In Genito-Urinary System, inspection reveals testicles correctly positioned with no swelling, infection, or enlargement. Palpation reveals no pain or enlarged prostate, percussion reveals no fluid collection in scrotum and auscultation reveals normal bowel sounds (Black & Hawks, 2005).
Laboratory Investigations: FBS – 97 mg/dl, Na(130-143mEq/dl) – 139 mEq / dl, K+ (3.5-5 mg/dl) – 3.7 mEq / dl, Urea(8-35mg/dl)-31 mg / dl, Sr. Cr (0.6-1.6 mg/ dl)- 1.1 mg/ dl, Other investigations, electro cardio gram -Right Bundle Branch Block, enlarged left atrium and normal axis. This information means that client neglected a health problem for 1month; Client has acute pain at surgical site. Client has family history of previous hernia, and risk for recurrence of intususception. Client has a risk for recurrence secondary to constipation. Client has risk for infection due to age and insufficient knowledge. Client is at risk of developing complications of high blood pressure. Client requires health maintenance education. Client requires pain management. Client understands to take care of his health risks and agrees to comply with these aspects. Based on the assessment done, i.e. Based on the clinical judgment of client’s actual and potential health problems, the nursing diagnoses are formed (Black & Hawks, 2005).
Nursing diagnosis: In nursing process, the data collection by assessment is used to derive nursing diagnosis According to King in process of this goal attainment; the problem is identified by the nurse, concerns and hindrances about who should be approached for help (Black & Hawks, 2005).
1. Acute pain related to surgical incision
2. Risk for infection related to surgical incision
3. Bed rest related constipation, narcotic pain relievers and nil by mouth or soft diet
4. Deficient knowledge regarding the treatment and home care
5. Health maintenance, ineffective
Planning: Post diagnosis, interventions planning, for problem solving done. In goal attainment, by setting the goal and making the decisions, and agreeing on the ways for achievement of goal, planning is presented. Transactions’ this part and participation of client’s is encouraged in decision making on the means of goal achievement. Goal identification and achievement planning for goals, in the traditional nursing process, planning is harmonious with this step (Black & Hawks, 2005).
I think that following goals are in best interest of the client.
1. The client will feel comfortable, as evidenced by a reduced pain, and be able to sleep and rest.
2. The client will have no infection as evidenced by normal vital signs.
3. The client will have better elimination of bowels, as evidenced by strain less elimination of stool.
4. Client will acquire sufficient knowledge about care at home and the treatment.
5. Client will attend to health problems promptly
Client’s goals are to be pain free, have faster healing, sufficient bowel motion, getting enough knowledge regarding health issues. Professional goals are matching with the client’s goals. (Black & Hawks, 2005).
The priority goals are pain relief, being free of infection, enough bowel motion, improved knowledge of health issues, promptly attending to health issues, working with the nurses and doctors, improving knowledge, revealing necessary information about health issues are the client perceptions as the best means of goal achievement. The client’s willingness to work towards the goal is important. Following are the goals required (Black & Hawks, 2005).
Goal 1: Assess the pain characteristics, administer meds prescribed, response monitoring to drug regime, provide care in calm and efficient manner to provide reassurance to the client and reduce his anxiety, and according to client’s requests provide a comfortable position (Black & Hawks, 2005).
Goal 2: Monitor vital signs; administer antibiotics as advised, use aseptic techniques while changing dressing, kept the surgical wound site clean, report surgeon regarding early signs of infection (Black & Hawks, 2005).
Goal 3: Make sure that the client has sufficient bulk in diet and is taking enough intake of fluid, advice to prevent straining, and to avoid valsalva maneuvers, advise to consult treating surgeon for meds (Black & Hawks, 2005).
Goal 4: Measures of treatment and benefits should be explained to client in a language that patient understands. Nurse should explain and demonstrate the care at home, doubts must be clarified of the client as the client may present with some important matters. To reinforce teaching, the information should be repeated as necessary (Black & Hawks, 2005).
Goal 5: Health education about restriction of lifting heavy weight (more than 20kg) for 6 months, further treatment as necessary, control of diet for his high blood pressure, measures of rehabilitation for better lifestyle promotion, for regular check-ups for recurrence of intussusceptions (Black & Hawks, 2005).
There are short-term and long term goals. Some modifications are required based on mutual agreement. Pain is tolerable to the client and requires no immediate medication, constipation is mild and does not need treatment, and other measures are mutually agreed. Actual activities are involved in implementation of nursing process, to achieve the goals. The result of this step is transactions. Transactions takes place because other person perceives the circumstances, interprets these perceptions, and acting in response. Action-reactions lead to transactions which has a common view and obligation. Implementation is reflected in this step of the traditional nursing process (Black & Hawks, 2005).
I am following the agreement between the client and me. I am carrying out the actions in a manner that is mutually acceptable in line with the set goals. I prioritize the actions to carry out; a few things require immediate actions. Others are carried out during hospitalization until 15 April. The reason, I am carrying out the action, because client’s condition demands nursing care. It is expected to reach identified goals by carrying out the action. Evaluation involves finding out if the goals are met or not. As King describes, evaluation tells us about goal attainment and effective nursing care. My actions are helpful to the client acquire mutual specific goals. Short-term goals must be met before client is discharge from hospital (Black & Hawks, 2005).
Long-term goals said to be met, because the client is motivated to continue care at home. All of the actions are working. Client’s response to my actions is that he is satisfied with my actions. Client’s age is a worrisome factor in achievement of goal regarding maintenance of health. Health teaching needs to be according to stage of development, and with family member involved in client care. (Black & Hawks, 2005).
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