Monday, July 28, 2008

Reflections from the Past and a Vision for the Future: King’s Theory and Its Application




Danela C. Oloresisimo, RN; Geraldine Mendoza, RN; Rosalie P. Naco, RN;

Paolo Antonio M. Morales, RN; Ernesto F. Mania, RN; Charlotte Marcelino, RN


“What is Human Nature?...Aristotelian understanding of being human is presented as the philosophical core of King’s conceptual system. King’s theory then turns to what Aristotle teaches about the composition of the world and what it means to be a human being. Wallace’s life-powers model of the soul brings these insights into contemporary thought. Aristotelian philosophy completes King’s account of the personal system by providing insight into what it is to be human.”

- Beverly J. B. Whelton, 1999



Imogene King “BORN TO FLY”


video

*George, J.B. (2002). Lavin, M.A. & Killeen, M.B. (2008).

Tomey, A.M. & Alligood, M.R. (2002).Messmer, P.R. (2007).


The Goal Attainment Theory

In the mid 1960s, Imogene King formulated a conceptual nursing model with the thought that man are like open systems that interact with his environment (King, 1981). She started to formulate this model, together with the Theory of Goal Attainment, during the period when nurses were trying to be scientists and professional practitioners. King intentionally designed a conceptual nursing framework as a forerunner to a theory that explains the rationale for the actions of nurses (Fawcett, 2001). The need to choose fundamental content of a new masteral nursing degree program prompted King to formulate her conceptual model (King, 1988).


King (1981) refined concepts into a nursing theory that consisted of the following bases:

1. An open systems framework as the basis of goal attainment.

2. Nursing as a major system within the health care system.

3. Nursing process emphasis on the interpersonal process.


King’s concept of Man as a reactive being—who is aware of his environment and his awareness—makes him respond based on his perceptions, expectations and needs. Man as a time-oriented being is usually controlled by time orientation. Man as a social being has a continuous exchange of transactions with others and with the environment (King, 1981).




King (1981) defines Health as:


Health is a dynamic, ever changing process that is a state of being. It is not a point to be achieved; it is an ongoing fluid existence, rather than a static state.



Kings’ Concept of Nursing (1981):

1. Nursing pertains to discernible nurse-client interaction, whose focus is to assist the individual to sustain health and act in a fitting function.

2. It is considered as an interpersonal course of action, reaction, interaction and transaction. The interaction is influenced by both the perceptions of the nurse and the client.

3. Nursing encourages, sustains and brings back health as well as provides care for the sick, the injured, or the dying patient.

4. It is a service occupation that addresses a social need.

5. To nurse means to plan, implement, and evaluate nursing care.

6. Nursing motivates a nurse and a patient to exchange information about their views (if such are correct, then goals are realized, development and growth are improved, which then results in effective nursing care; furthermore, when a nurse and a patient recognize harmonious role performance and expectations, transactions happen; but when role conflict arises, stress transpires)

7. Nursing employs a goal-oriented strategy wherein people within a social system act together; the nurse provides special skills and knowledge into the nursing process, while the patient offers perception and self-knowledge.


King (1990, 1997) developed her Conceptual System to identify concepts that are important to the nursing profession, to help in developing the scientific base for nursing knowledge, and to provide a potent tool to systematize nursing curricula as well as guides to nursing practice that support quality care in all nursing settings. King’s nursing paradigm—which seeks to integrate the personal, interpersonal and social systems that influence a patient’s health—is an important model for health care in the present and beyond (Whelton, 1999). Her interacting conceptual system for nursing and her theory of goal attainment have been included in every major nursing theory text, are taught to millions of nursing students throughout the world, outline the basis of nursing education programs, and are implemented in various nursing service settings (Frey et al., 2002).


King’s theory underscores the significance of the nurse-patient interaction which considers this interface as an open system which is in continuing contact with various environmental factors (King, 1989; George, 2002). King’s model is composed of three interacting systems: personal (corresponding to individuals), interpersonal (corresponding to health care settings interactions), and social (corresponding to larger institutions, like communities and hospitals), and is composed of four key concepts, namely: health, interpersonal relations, perceptions and social systems. King argues, in her Theory of Goal Attainment, that patients’ objectives are addressed primarily through the nurse-patient interaction (Williams, 2001).


An Inference of Ethical and Philosophical Aspect of Goal Attainment Theory

The following are guidelines for using knowledge of the concepts of the theory of goal attainment and of the transaction process together with the code for nurses and standards of clinical nursing practice:

1. Assist patient and family determine the key values in the situation and persuade them to contemplate within their value system as well as the outcomes of action they choose to undertake in the situation.

2. Assist patient and family in making decisions by reflecting on their value system based on the information that you provide; stress on their circumstances as expressed by them; however, avoid making decisions for them.

3. Try to be skillful in determining choices in each nursing situation and search these with the patient and family.

4. Determine those components in the situation that can be controlled and changed as well as those which cannot; focus your efforts and energy on change and control.

5. Issues on ethical may occur in considering (a) right to life, (b) right to die, and (c) right to information to be informed.


Employing knowledge of the concepts in the theory of goal attainment and in the transaction process will enable nurses to focus on the fact that each and individual must be treated with respect as human beings of equal importance who have their own set of personal values. Fundamental theoretical knowledge is the key in undertaking responsibility in making ethical decisions in healthcare and nursing (King, 1999).



The Application

The perspective of King on the science of nursing and its role in developing knowledge for the discipline offer an outline of the use and expansion of the conceptual framework. King’s perspective also seeks to determine areas that could optimize the contribution of nursing practice and research as well as evaluate the prospects for continuing contributions in the present time. The Systems Theory and the Theory of Goal Attainment of King directly merge with the classification systems like nursing outcomes, interventions, and diagnoses, indicating that the Theory of Goal Attainment is crucial to evidence-based nursing practice (Malinski, 2002).


King’s Theory of Goal Attainment can be used in the emergency room setting. The assessment phase of the nursing process can take in the concepts associated with the personal system. The patient’s feelings of perception, self body image, growth and development, time and space must be considered after doing the primary survey of airway, breathing and circulation. An example is a trauma patient in the emergency room who had a traumatic amputation of an arm due to a motor vehicle accident. Once the patient is hemodynamically stable the nurse’s attention is refocused on assisting the patient cope with the feelings of loss, separation and anger that he was experiencing. Attempting to restore the patient’s self-esteem in the light of the traumatic loss was a mutually established goal between the nurse and the client. It was also important for the nurse to realize that the patient’s perceptual field was narrowed because of the pain and emotion that he was experiencing. King’s theory highlights the importance of the participation of the individuals in decision making and deals with the choices, alternatives, and outcomes of nursing care. The theory offers insight into the nurses’ interactions with the individuals and groups within the environment (Williams, 2001).


The initial grumble of patients and his significant others is the length of waiting time. Waiting time for more than an hour is an infinity for patients but passes swiftly for a busy nurse. King (1981) accentuated that waiting makes time seem even longer. To address the problem, the installation of televisions and telephones in patient’s room has proven successful as it helps the patients pass the time and reduce some apprehensions. In an environment that requires one to be reactive and responsive, clients often perceive nurses as being too busy or too hurried. King (1981) encouraged nurses to be aware of how they present themselves to their clients because the manner in which nurses enter a client’s room sets the tone for the entire encounter. Poor communication skills lead to poor transactions and interactions between the nurse and the client. Poor communication skills also affect goal setting and goal attainment (Williams, 2001).


During a home visit in a community setting, the nurse and the patient interrelate and will possibly meet for the first time. A corresponding action and reaction happens through the nurse’s assessment, while the patient provides self knowledge and perception of important problems. To enable the nurse to understand and incorporate knowledge and science that will be used, perception of the patient and the nurse will be the foundation to gather and interpret data. Thus, during the assessment, the nurse’s diagnosis will be made as a product of reciprocal sharing with the patient. Planning transpires based on the decision-making regarding the search for ways to reach objectives. While the patients are asked to share, they are not supposed to do so. The efficacy of nursing care and the realization of the goal of the patient are demonstrated by assessment. The value of shared participation in interaction concentrates on the welfare and needs of the patient as the planning process are made together, stressing on reciprocity to reach goal attainment using a Goal Oriented Nursing Record (GONR) (George, 1999).



A female patient admitted at the OB Gyne ward status post-NSD was breastfeeding her newborn son. I asked her how she was. She said, "I am alright, I can stand on my own", I asked her if she took a bath already, she said, "Not, yet! I am planning to do it after 2 weeks. My grandmother firmly believed in that superstition". Knowing how important hygiene is, especially to a nursing mother, I told her that taking a bath is an important routine that a nursing mother should do. I enumerated the advantages of it and at the same time presented to her the disadvantages of not taking a bath. I told her that I respect what her grandmother has told her however, I cannot agree with her. She looked at me as if she is asking for an assurance that taking a bath is not harmful to her. She uttered, "Really, can I take a bath now?" and I replied, “Yes, of course”. Her question confirmed that the interaction that happened helped to attain our goal of proper hygiene. Element of the theory of Imogene King was applied specifically in interpersonal system and social system. The interaction was a dyad (2 people interacting), the perception of the patient was changed because of the communication that took place that gives education to a knowledge deficit patient. Another example is the patient and significant others compliance, if the patient per se does not understand the importance of a certain intervention or medication, cooperation and adherence is very difficult to achieve. But once the nurse educated them with proper NPI and therapeutic communication, compliance and adherence to medical regimen can be achieved.


King’s Goal Attainment Theory (Client-Centered Theory) is indeed what we are practicing in the daily routine in the hospital and in any other clinical setting. Applying King’s concept of Man as a reactive being, thus, make this awareness to respond in the environment. Giving the patient the pertinent information of what is going to happen or what is happening will lessen the patient’s anxiety that contributes to tachycardia, restlessness and give them a sense of control of the situation. According to the Nurse-Client Dynamics—man is a time-oriented being and man as a social being have a language and means of transactions to link and facilitates interpersonal communication in which is the most important aspect of care no matter what the situation the patient is in. As per the Nurse–Client–Environment Dynamics, using the goal-oriented nursing record which consists of database, problem list, goal list, nursing care plan and progress notes will be communicating information and endorsement through the goal directed approach in open system of the environment.


References:

Fawcett, J. (2001). The Nurse Theorists: 21st-Century Updates—Imogene M. King. Nursing Science Quarterly, 14(4), 311–315.

Frey, M.A., Norris, D.M. & Sieloff, C.L. (2002). King’s Conceptual System and Theory of Goal Attainment: Past, Present, and Future. Nursing Science Quarterly, 15(2), 107–112.

George, J.B. (2002). King’s Conceptual System. In George, J.B. (Ed.), Nursing Theories: The Base for Professional Nursing Practice (5th ed.), New Jersey, USA: Prentice Hall, 241–265.

George, J.B. (1999). Imogene King. Nursing Theories: The Base for Professional Nursing Practice (4th ed.), New Jersey, USA: Prentice Hall, 222–224.

King, I.M. (1999). A Theory of Goal Attainment: Philosophical and Ethical Implications. Nursing Science Quarterly, 12(4), 292–296.

King, I.M. (1997). King’s theory of goal attainment in practice. Nursing Science Quarterly, 10, 180–185.

King, I.M. (1990). Health as the goal for nursing. Nursing Science Quarterly, 3, 123–128.

King, I.M. (1989). King’s general system framework and theory. J.P. Riehl-Sisca (Ed.), Conceptual Models for Nursing Practice. Norwalk, CT: Appleton & Lange, 149–158.

King, I. M. (1988). The nurse theorists: Portraits of excellence—Imogene King [Videotape and CD]. Athens, OH: Fuld Institute for Technology in Nursing Education.

King, I.M. (1981). A Theory for Nursing: Systems, Concepts, Process. New York: Wiley.

Lavin, M.A. & Killeen, M.B. (2008). Tribute to Imogene King. International Journal of Nursing Terminologies and Classifications, 19(2), 44–47.

Malinski, V.M. (2002). Research Derived from King’s Conceptual System. Nursing Science Quarterly, 15, 107.

Messmer, P.R. (2007). Tribute to the Theorists: Imogene King Over the Years. Nursing Science Quarterly, 20(3), 198.

Tomey, A.M. & Alligood, M.R. (2002). Nursing Theorists and Their Work. 5th ed. Missouri: Mosby, 336–348.

Whelton, B.J.B. (1999). The Philosophical Core of King’s Conceptual System. Nursing Science Quarterly, 12(2), 158–163.

Williams, L.A. (2001). Imogene King’s Interacting Systems Theory: Application in Emergency and Rural Nursing. Online Journal of Nursing and Health Care, 2(1), 25–30.