Application of a Theory-Goal Attainment Theory

Application to Practice of King’s Goal Attainment Theory

At a time when nursing was in its early stages of being considered as a science discipline, Imogene King conceptualized her theory with an approach to building a relationship between the discipline and research to build scientific knowledge.  King was focused on expanding the knowledge base of the practice and began formulating her theory while working as a Professor at Loyola University.  Her theory is coined from the idea of Karl Ludwig von Bertalanffy’s general theory system, a theory of interrelatedness to show how each system connects to tell a story.  As such, the conceptual system’s background was the study of systems as a whole and not in parts, to gain a better understanding of the bigger picture.  First presentation of Imogene King’s theory of goal attainment was in the 1960s. The theory defines an interpersonal relationship between a nurse and a client, wherein the client learns to develop and attain specific goals.  This theory is based on the affiliation formed between a nurse and her client, with a notion that the care of human beings is the focus of nursing.  “An overall assumption is that the focus of nursing is human beings interacting with their environment leading to health” (King 2007, p. 109).  The individuals involved in the relationship diligently work together and communicate information, congruently set desired goals that are mutually acceptable.  Together, they work as a team to formulate a plan to accomplish those goals.  The association of each member is unique, and they each play an active role, and each party brings their own varied perception and level of comprehension to the bond. 

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The purpose of this paper is to show an approach to using the goal attainment theory in practice.  Interactions of each member of the relationship allows for growth and development; However, the concepts of theory inform its readers of factors that can affect the trajectory of attaining goals.  Factors such as, roles, stress, space, and time are hurdles that need to be overcome to achieve a desire outcome.  One major concern of this theory is functional status of the nurse in relation to patients.  With the well-being of each patient remaining a concern for nurses; the understanding and development of this theory helps nurse to gain light on helping patients to realize and achieving their goals.  In gaining an understanding of this application, a case study will be utilized to show how this theory can be put into action. 

Theory Description

King’s aim in developing her theory was to prove that nursing is a multifaceted role that is firmly rooted on research, she worked to expand the paradigms of nursing concepts.  King’s theory of goal attainment is based on a philosophical concern of human beings and their interaction with their environment.  This system consists of three concepts, which was collective to the role of nursing: Social system, health perception and interpersonal relationships.  King’s theory detailed the vitality of the participation of each party within the relationship in actively making decisions and is reflective on interaction, perception, and communication.  Effective communication helps to gather pertinent information to set mutual goals.  As such, King’s belief in the practice is detailed in her theory.  She believed that nursing is varied from other health discipline by the tasks performed by nurses, their goal is the care of the patient as well as well-being maintenance.  The role of nursing, as seen by King is achieved by “assisting individuals to attain, maintain, or restore health.  To achieve this outcome nurses and clients engage in interactions of verbal and nonverbal communication” (Sitzman and Eichelberge, 2017, p. 145).  She had values and beliefs that were strongly upheld by the nursing profession.  Values of strength, honesty, truth and morality all of which commiserates with King’s belief, rings true to those honored by the American Nurses Association.  “King’s values and beliefs include honesty, integrity, justice, and respect for every human being.  There are three basic rights relative to the autonomy of the nurse and the autonomy of the patient: privacy, self-determination, and information to make informed choices” (King 2007, p. 109).  Each person in a therapeutic relationship is autonomous, and they ought to make their voices heard.  “The focus of nursing is the care of people, with explicit goals.  This goal is health, meaning that nursing phenomena are concerned with the health of individuals, the health of groups and the health of society” (King 1997, p. 180).

Analysis and Evaluation

Nurses work within domains of families, individuals and communities to conduct transactions with the aim of goal attainment to maintain a state of well-being for clients.  Dr. Imogene King four levels of meta-paradigm within her theory; health, person, environment and nursing.  Human beings are unique in their own way and are capable of making decisions, they think, feel and perceive.  Each human being has three central needs, these establish the need for health information, the need for preventative measures, and assistance with self-care deficits when needed.  Health, she explains, is life experiences which is a continuous alteration and adaptation to stressors of the environment.  The Environment is the realm of human interactions, it allows nurses to perceive the clients and their ability to adapt to the stressors of the environ. Stressors can either be internal or external, and humans have the capability to adjust to stressors and the continuous changes that often occur.  Nursing is a role where actions and interactions help to assist clients in attaining and maintaining ideal health.

The theory assumes explicitly that the care of human beings is the focus of nursing, with a goal of health for the consort.  Human beings interact constantly with their environment.  As such, each person understands their environment and can make transactions within that environment.  An assumption is made that nurse and client communicate, interact, set goals and frame transactions to achieve those goals.  With these assumptions being identified, the theory proposes that once an accurate interaction is achieved within the nurse-client dyad, a transaction will ultimately occur.

Communication is vital in achieving a goal, when people interact, an understanding or misunderstanding occur, this is dependent on the level of interference.  “Mutual goals are based on the identification of problems, changes in health, perceptions of problems and sharing of information in order to achieve goals” (Araújo, Silva, Moreira, Almeida, Freitas, & Guedes 2018, p. 1095).  The process of interacting with patients follows the trend of the nursing process (as depicted in chart #1: nursing process), with a system of interrelated actions.  Assessment is the perception of the client and nurse, the initial meet.  The diagnostic phase is the communication process between both parties where both parties interact with each other and concerns are identified, judgement is made.  Judgement leads to reaction and if both parties are not in congruence with each other.  The planning phase is where a decision-making action pertaining to implied and desire goals is determined (when possible).  Agreement to ways of achieving goals are made and a transaction is initiated.  Implementation phase constitutes continuation of a transaction, one that is made between the nurse and client.  Evaluation is used to determined if goals are attained or not.  If not, then the transaction needs to be reevaluated and a new plan is then developed.  Goal attainment is achieved when a service is offered to patient by a nurse, the goal developed is one formulated through a reciprocal relationship, where mutual and purposeful interactions are evident. 

In shaping the goals with patient, a series of actions are determined by the nurse.  These strategies guide the nurse in organizing information about the patient’s care.  In table #1, the nurse uses information and data that are individualized to the patient and tailored to meet the specific needs of the client. In developing a careful, specific and precise plan of care the nurse first needs to collect data by assessing the patient. Next, this data is analyzed and organized to help with the formulation of nursing diagnoses.  The nurse then needs to set priorities in determining the best steps to take.  By doing this, the nurse along with the patient establishes a goal and set desired outcomes to achieve.  The interventions that are essential to fulfill the goals are then determined.  To give clarity, rationales are sought out, this helps the nurse to evaluate the plan and make any adjustments that may be required. 

Nurses communicate with their patients daily, and without realizing it, their role provides them with the opportunity to form a bond with patent.  This theory was chosen as communication on my part as a nurse is vital in helping the patients achieve an amicable outcome.  Before reading and understanding the concepts of Dr. King’s theory, I would consider myself a novice in the comprehension of this theory.  The familiarity that each person has a role of health maintenance and a level well-being to accomplish was understandable.  However, the direction and how to effectively help these patients was somewhat lacking.  The nurse does not control outcomes but work together with the clients to achieve the desired goals.  Clients are autonomous and are therefore, responsible for their own well-being.  This theory helped me gain clarity on the trajectory to help a patient develop their goals.  It helped me to understand how perception can miscue meanings, lead to bad judgement and ineffective planning.  Building a bond and remaining true to the needs of the client is vital, as learned from this theory. This bond is a part of a therapeutic relationship, one that helps both parties to gain a better understanding of the situation.  This level of understanding is communicated in chart #2 (goal attainment transaction diagram).  As nurses we each need to help our client maintain an optimal level of health, by doing this we use proficient communication skills to develop an understanding to help each patient recognize their need.  The theory of goal attainment helps us gain skills necessary to guide our patients.  The era of healthcare is focused on a patient-centered care.  “King’s theory is even more relevant as healthcare has placed an increased emphasis on client needs and preferences. Thus, providing an important lens through which to evaluate the nurse-client dyads’ implications for goal-setting and client satisfaction related to functional status” (Caceres, B. A. 2015, p. 151).  Communication is vital in all aspects of nursing and nurses communicate with their client to gain an understanding of their needs, as such, the theory of goal attainment can be applied in a variety of nurse-client settings.  Whether inpatient or outpatient use, the theory is readily understood.  It is broken down in term that does not speak complexity.

With the theory having multiple concepts, it is complex, however, it is easily understood and clearly defined as Dr. King sought to portray the theory development.  The theorist maintains consistency with her breakdown of each layer of the theoretical concepts and showing connectedness to each level.  Its adequate, as the author gave an extensive general idea of expected standards required by each party involved.  The role of the nurse was clearly defined as well as that of the patient.  It is therefore, logically relevant for the practice of nursing. There is reality convergenceas the basic premise of this theory is accepted and the author builds on her idea of patients and nurses working together to achieve a mutual goal. 

In conclusion, the Theory of goal attainment focuses on the nurse-patient relationship.  Mutual goal setting can be attained while incorporating the models of the interrelated systems. The nursing paradigms and nursing process outline methods by which goals are attained by the patient and nurse together. 

Case Study

Kim is a 30-year-old female who was admitted for evaluation after palpating a lump in her left breast.  She noticed an unusual drainage from the breast and started feeling moderate pain.  A mammogram and biopsy were done, which revealed stage three (3) breast cancer.  Kim’s breast tumor is 8 cm, and there is fixed lymph node involvement in the axillary. Kim was noted to have infiltrating ductal carcinoma of the left breast.  Kim underwent a total mastectomy to her left breast, soon after the diagnosis.  Her medical history revealed that she infrequently visited her primary physician.  Kim was oblivious to her medical condition, and only noticed the lump after the other symptoms were present.  She stands at 5 feet, 8 inches tall and weighs 115 lbs. She normally weighs roughly 130 lbs.  She is married, and currently lives with her husband and three children in her mother-in-law’s home. she doesn’t appear to be happy about the living arrangements and states that the house is unsanitary.  She is a stay-at-home mother, and her husband is currently unemployed.  Kim is stable after surgery and doing well but has issues emptying her bladder.  She has 2 JP tubes in place for drainage.  She complains of constant postoperative pain and rates her pain scale at 6-7/10 and is also experiencing nausea and emesis.  She will need to perform intermittent self-catheterization as well as empty and record her JP drainage once discharged.  She is prescribed a prophylactic antibiotic, an analgesic as needed for pain and an antiemetic for nausea. She will also be receiving chemotherapy on an outpatient basis. Kim is tearful and upset and expresses concern over her future and the future of her three children.  She is distraught about her relationship with her husband and her current living arrangements.  Kim states that she believes this cancer is a punishment for her past life.

Table #1: care plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Weight loss from 130 to 115 pounds.

Constant report of post-operative pain.  Report of pain level on a scale of 6-7/10

Kim is tearful, and expresses concerns about her future and that of her children

 

Inability to empty bladder and retaining urine

Imbalanced nutrition as evidenced by a drop in weight from 130 to 115

Acute pain related to left breast mastectomy as evidence by Kim’s complains of pain

Fear related to medical diagnosis as characterized by feelings of self-doubt and concerns of her children’s future.

Impaired urinary elimination related to retention as evidenced by the need for catheterization

Ensure that Kim is sustaining or gaining weight. By the date of discharge, Kim will increase her caloric intake.

Kim will be consuming less opioids by the date of her discharge.

Maintain a tolerable pain scale.

Maintain a calm environment, offer encouragement and guidance.  Ensures that Kim will agree to participate in outpatient social services or group therapy with others who have gone through similar situations.

Kim demonstrates proper technique of self catheterizations. Show proper hand washing

Refer Kim to dietician.  Offer supplements to increase caloric intake.  Encourage Kim to start increasing her dietary intake before discharge.

Provide analgesic as needed.  Encourage patient to reposition self as well as the use of music and calming scenery to relieve discomfort.

 

Provided reassurance that help is imminent. Maintain a relaxed and accepting demeanor while communicating with Kim.  Show empathy. Have social workers and counsellors speak with Kim before discharge.

Measure post void residual.  Encourage adequate fluid intake.

Dietician can help daily nutrient requirements to promote nutritional intake.  Added calories help with weight gain.

The discomfort of pain can alter the patient’s response to care and willingness to participate

Reassure patient that seeking help is a step towards a resolution.  A none-threatening environment can promote stability.

Adequate hydration promotes urinary output and limits UTI.

Determine if Kim is following the dietician’s recommendation.  Ascertain if dietary intake has increased.  Weight patient regularly.

As the patient pain level decreased.  Is patient managing the pain well.  Determine what methods of pain management works best for Kim. Has the demand for opioid decreased

Determine whether Kim participated in social service meetings.  Evaluate Kim’s thoughts, seek to determine if her level of self-doubt has subsided or increases.

Kim should be able to show proper demonstration of self-catheterization before discharge.

chart #1: NURSING PROCESS

Perception                                            Nurse understands the Kim is fearful, unsure about her future and she is unhappy with her marriage and living situation. She is pain.

Judgement                                 Kim needs guidance to help her through her struggles.

Action                        Make arrangement for social service visit.  Inform Kim outpatient community resources and plan for Kim to participate in outpatient care.  Reduce pain, and bladder discomfort.  Reduce anxiety and help to alleviate or reduce stressors.

Perception                                            Patient believes her disease is of her own fault.  She is, however, willing to partake in endeavors to a healthy outcome as she willingly communicates her fears.

Judgement                                       Kim may feel that the nurse openly respects her and is willing to listen to her plight. Therefore, building trust

Action                                       Willingly participates in wound care teaching. Willing accept social service intervention. 

       NURSE PATIENT

 

     

    

      Reaction

Acceptance of each individual role with mutual goal setting (informative communication process) Patient and nurse work to develop a plan to help in healing process

     

SOCIAL PERSUASION

Nurse informs Kim that she believes she can succeed, and she will heal adequately. Offering reassurance that help is imminent.

 

 

Interaction

Communicating needs, by patient telling the nurse about her discomfort and family orientation, both parties work together to sort through emotional barriers.  Both parties obtain feedback from each other during their communicative methods.  Kim communicates her pain tolerance with the nurse.

 

 

Transaction

Nurse set expectations with Kim, which will help to sustain a healthy healing condition.  Kim is willing to work with social workers and community programs to attain positive coping strategies. She admits to flaws in her life that might deter her from recovering.  Both parties work together to maintain tolerable pain scale. A calm environment with minimal distractions is maintained.

CHART#2  GOAL ATTAINMENT TRANSACTION DIAGRAM

References

Araújo, E. S. S., Silva, L. de F. da, Moreira, T. M. M., Almeida, P. C. de, Freitas, M. C. de, & Guedes, M. V. C. (2018). Nursing care to patients with diabetes based on King’s Theory. Revista Brasileira De Enfermagem, 71(3), 1092–1098. https://doiorg.lehman.ezproxy.cuny.edu/10.1590/0034-7167-2016-0268

Bertalanffy, L. V., & Sutherland, J. W. (1974). General Systems Theory: Foundations, Developments, Applications. IEEE Transactions on Systems, Man, and Cybernetics, SMC-4(6), 592-592. doi:10.1109/tsmc.1974.4309376

Caceres, B. A. (2015). King’s Theory of Goal Attainment. Nursing Science Quarterly, 28(2), 151-155. doi:10.1177/0894318415571601

Fronczek, A. E., & Rouhana, N. A. (2018). Attaining Mutual Goals in Telehealth Encounters: Utilizing King’s Framework for Telenursing Practice. Nursing Science Quarterly, 31(3), 233-236. doi:10.1177/0894318418774884

King, I. M. (1997). Kings Theory of Goal Attainment in Practice. Nursing Science Quarterly, 10(4), 180-185. doi:10.1177/089431849701000411

King, I. M. (2007). Kings Conceptual System, Theory of Goal Attainment, and Transaction Process in the 21st Century. Nursing Science Quarterly, 20(2), 109-111. doi:10.1177/0894318407299846

Sitzman, K., & Eichelberger, L. W. (2017). Understanding the work of nurse theorists: A creative beginning (3rd ed.). Burlington, MA: Jones & Bartlett Learning.