Imogene King: Theory of Goal Attainment (Study Guide)

You do not move a patient toward health alone. You and the patient read the situation, set goals together, and act on them together. That is the whole engine of Imogene King's Theory of Goal Attainment: nursing as a process of action, reaction, and interaction in which nurse and client share what they perceive and agree on how to reach a goal.

Biography of Imogene King

Imogene Martina King (January 30, 1923 to December 24, 2007) developed the Theory of Goal Attainment in the early 1960s. Her work is taught to nursing students worldwide and applied across service settings, and she shaped nursing education, practice, and research as an active leader in the profession.

Early Life and Education

King was born on January 30, 1923, in West Point, Iowa. She planned on teaching, but her uncle, the town surgeon, offered to pay her nursing school tuition, and she took it, partly as a way out of small-town life.

In 1945 she earned a nursing diploma from St. John's Hospital School of Nursing in St. Louis, Missouri. Working various staff nurse roles, she earned a Bachelor of Science in Nursing Education from St. Louis University in 1948 and a Master of Science in Nursing from St. Louis University in 1957. She then studied under Mildred Montag, her dissertation chair, at Teachers College, Columbia University, New York, and received her EdD in 1961.

Career and Appointments

After her 1945 diploma, King worked in staff nurse roles, then from 1947 to 1958 taught Medical-Surgical nursing and served as assistant director at St. John's Hospital School of Nursing. From 1961 to 1966 she built a master's degree program in nursing on a conceptual framework at Loyola University in Chicago. Her first theory article ran in 1964 in Nursing Science, edited by nurse theorist Martha Rogers.

Under Jessie Scott, King served as Assistant Chief of the Research Grants Branch, Division of Nursing, at the U.S. Department of Health, Education, and Welfare from 1966 to 1968. While in Washington, DC, she published "A Conceptual Frame of Reference for Nursing" in Nursing Research (1968).

In 1969 she ran a World Health Organization nursing research seminar in Manila, Philippines, where she met Midori Sugimori of Japan. Sugimori later translated King's two theory books into Japanese, strongly influencing nursing education there, and Tomomi Kameoka's doctoral dissertation tested the theory of goal attainment in Japan. King was present when Kameoka presented that research at the honor society's 2001 Biennial Convention.

From 1968 to 1972 King directed the School of Nursing at Ohio State University in Columbus, then returned to Chicago in 1972 as a professor in the Loyola University graduate program. From 1978 to 1980 she was Coordinator of Research in Clinical Nursing at the Loyola Medical Center Department of Nursing. From 1972 to 1975 she sat on the Defense Advisory Committee on Women in the Services for the U.S. Department of Defense, and she was elected alderman for a 4-year term (1975 to 1979) in Ward 2 at Wood Dale, Illinois.

In 1980 King was appointed professor at the University of South Florida College of Nursing in Tampa, where she helped plan care through her conceptual system at organizations including Tampa General Hospital. She retired in 1990 and was named professor emeritus at the University of South Florida, though she stayed available to students and faculty and went "round the clock" to implement her theory at Tampa General Hospital. She served on a nursing advisory board and guest lectured at the University of Tampa.

King was keynote speaker at two STTI theory conferences in 1992 and presented at regional, national, and international STTI conferences. A long-time American Nurses Association (ANA) member through the Missouri Nurses Association and active in Illinois and Ohio, she joined the Florida Nurses' Association (FNA), FNA District 4, Tampa, after moving to Florida. She held offices including Florida Nurses Foundation president, served on the FNA and FNA District IV boards, and was an FNA delegate to the ANA House of Delegates.

In 2000 she was keynote speaker for the 37th Annual Isabel Maitland Stewart Conference in Research in Nursing at Teachers College, Columbia University, pleased that Mildred Montag attended. The King International Nursing Group (K.I.N.G.) was created to spread and apply King's conceptual system, the Theory of Goal Attainment, and related theories.

Works

King earned recognition as a theorist with Toward a Theory for Nursing: General Concepts of Human Behavior (1971) and A Theory for Nursing: Systems, Concepts, Process (1981), plus many articles. The 1971 book was published while she directed the School of Nursing at Ohio State, where she concluded that "a systematic representation of nursing is required ultimately for developing a science to accompany a century or more of art in the everyday world of nursing." It won the American Journal of Nursing Book of the Year Award in 1973. Her third book, Curriculum and Instruction in Nursing: Concepts and Process, appeared in 1986. Other works include The Language of Nursing Theory and Metatheory. She authored book chapters as well, including in Frey & Sieloff's Advancing King's Systems Framework and Theory of Nursing (1995) and Sieloff and Frey's Middle Range Theories for Nursing Practice Using King's Conceptual System (2007).

Awards and Honors

The 1971 book won the American Journal of Nursing Book of the Year Award in 1973. In 1980 King received an honorary Ph.D. from Southern Illinois University. She was one of the original Sigma Theta Tau International (STTI) Virginia Henderson Fellows and received the STTI Elizabeth Russell Belford Founders Award for Excellence in Education in 1989. In 1994 she was inducted into the American Academy of Nursing (AAN) and served on the AAN Theory Expert Panel. She received the Jessie M. Scott Award in 1996, with Jessie Scott present. King was in the ANA House of Delegates to hear President Clinton's congratulations on the ANA's 100th anniversary, with his mother's admiration as a nurse anesthetist. In 1997 she received a gold medallion from Governor Chiles for advancing nursing in Florida. In May 1998 she received an honorary doctorate from Loyola University, which houses her "Nursing Collection." In 1999 she was inducted into the Teachers College, Columbia University Hall of Fame. In 2004 she was inducted into the FNA Hall of Fame and the ANA Hall of Fame, and she was named a Living Legend in 2005. She considered teaching students her most important accomplishment.

Death

Imogene King died on December 24, 2007, two days after a stroke. Patricia Quigley, Ph.D., ARNP, CRRN, FAAN, announced her passing: "May we all burn a candle today for the light that Imogene shined on us with her smile, laughter, knowledge, and passion for each day. We all shared in our love for her. Combining religion and science through nursing, her inspired voice was never weak, but strong with passion and conviction."

Midori Sugimori, Naomi Funashima, Kyoko Yokoyama, and Tomomi Kameoka, four Japanese nurses King had mentored, traveled to Florida to pay respects. Memorial services were held January 4 in St. Pete Beach, Florida, and January 19 in Fort Madison, Iowa, where she was buried. Patricia Messmer read the Nightingale Tribute, including a synopsis of King's career and a poem, "Imogene Was There." Seven green Irish roses symbolized the seven decades of her nursing career, and a Nightingale Lamp from the University of Pittsburgh, her graduation picture from St. John's Hospital School of Nursing, and a current photo were displayed.

Theory of Goal Attainment

King introduced the theory in the 1960s. Nursing is "a process of action, reaction, and interaction by which nurse and client share information about their perception in a nursing situation," and "a process of human interactions between nurse and client whereby each perceives the other and the situation, and through communication, they set goals, explore means, and agree on means to achieve goals." Action is a sequence of behaviors involving mental and physical activity; reaction is included in that sequence. The nurse's goal is to help individuals maintain health so they can function in their roles. The nurse's domain "includes promoting, maintaining, and restoring health, and caring for the sick, injured and dying," and her function is "to interpret information in the nursing process to plan, implement, and evaluate nursing care."

The factors affecting goal attainment are roles, stress, space, and time. The patient is a social being with three fundamental needs: health information, care that prevents illness, and care when unable to help themselves. Health involves continuous adjustment to stressors in the internal and external environment using available resources. The environment is the background for human interaction, both internal (transforming energy so people adjust to external change) and external (formal and informal organizations); the nurse is part of the patient's environment.

Propositions

(1) If perceptual interaction accuracy is present in nurse-patient interactions, the transaction will occur. (2) If the nurse and patient make the transaction, the goal or goals will be achieved. (3) If the goals are achieved, satisfaction will occur. (4) If the goals are achieved, effective nursing care will occur. (5) If transactions are made, growth and development will be enhanced. (6) If role expectations and role performance perceived by nurse and patient are congruent, the transaction will occur. (7) If role conflict is experienced by either or both, stress in the interaction will occur. (8) If a nurse with special knowledge communicates appropriate information to the patient, mutual goal-setting and goal achievement will occur.

Assumptions

King's view of human beings shaped her assumptions about environment, health, nursing, individuals, and interactions, built on the overall assumption that nursing focuses on human beings interacting with their environment toward health, meaning the ability to function in social roles. (1) Nursing's focus is the care of the human being (patient). (2) Its goal is the health care of both individuals and groups. (3) Human beings are open systems constantly interacting with their environments. (4) Nurse and patient communicate information, set goals mutually, and act to achieve them, which is also the basic assumption of the nursing process. (5) Patients perceive the world as a complete person making transactions with individuals and things. (6) The transaction is a life situation in which perceiver and perceived meet and the person enters as an active participant, and each is changed by the experience.

Three Interacting Systems

King's framework runs on three interacting systems: the personal system, the interpersonal system, and the social system. As interactions involve more people, complexity rises: two interacting individuals form a dyad, three a triad, four or more a small or large group.

Personal systems. Each individual is a personal system, such as a patient or nurse. The concepts are perception, self, growth and development, body image, space, and time. The self is "a composite of thoughts and feelings which constitute a person's awareness of his individual existence, his conception of who and what he is," a person's total subjective environment and inner world, the individual as known to the individual, that to which we refer when we say "I." Growth and development are the processes through which people move from a potential for achievement to the actualization of self, including continuous changes at the cellular, molecular, and behavioral levels. Body image is how one perceives one's body and others' reactions to one's appearance. Space exists in all directions, is the same everywhere, and is defined by the physical area called "territory" and by the behaviors of those occupying it. Time is "a duration between one event and another as uniquely experienced by each human being; it is the relation of one event to another event," a continuous flow of events in successive order implying change, a past and a future. King (1986) added learning as a personal-system subconcept but did not define it further.

Interpersonal systems. Formed by human beings interacting, understood through interaction, communication, transaction, role, and stress. Interactions are the observable behaviors of two or more individuals in mutual presence, a process of perception and communication between person and environment and between person and person, represented by goal-directed verbal and nonverbal behaviors. King (1990) defines communication as "a process whereby information is given from one person to another either directly in a face-to-face meeting or indirectly through telephone, television, or the written word." Transactions are "a process of interactions in which human beings communicate with the environment to achieve goals that are valued," goal-directed human behaviors; perception is "each person's representation of reality." Role is a set of behaviors expected of persons occupying a position in a social system, the rules defining rights and obligations, and it carries reciprocity, a person being giver at one time and taker at another. Stress is "a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance," an exchange of energy and information for regulation and control of stressors.

Social systems. The more comprehensive interacting system of groups that make up society, such as religious, educational, and health care systems, or an extended family's influence on growth and development. The concepts are organization, authority, power, status, and decision-making. Power is the capacity to use and mobilize resources in organizations to achieve goals, the process whereby persons influence others in a situation, a social force that organizes and maintains society; each person has potential power determined by individual resources and environmental forces. Status is "the position of an individual in a group or a group concerning other groups in an organization," accompanied by "privileges, duties, and obligation." Decision making is "a dynamic and systematic process by which goal-directed choice of perceived alternatives is made and acted upon by individuals or groups to answer a question and attain a goal" (King, 1990). King (1986) added control as a social-system subconcept but did not define it further.

Dynamic Conceptual System King interrelated interaction, perception, communication, transaction, self, role, stress, growth and development, time, and space into a goal attainment theory. The theory deals with a nurse-client dyad, each person bringing personal perceptions of self, role, and growth and development. Nurse and client communicate, first in interaction and then in transaction, to attain mutually set goals. The relationship occurs in space identified by their behaviors and in forward-moving time. King held that her "framework differs from other conceptual schemas in that it is concerned not with fragmenting human beings and the environment but with human transactions in different kinds of environments." The human process of interactions formed the basis for a model of transactions depicting the theoretical knowledge nurses use to help individuals and groups attain goals.

Theory of Goal Attainment and the Nursing Process

Assessment happens during the interaction. The nurse brings special knowledge and skills; the patient brings self-knowledge and the perception of the problems of concern. The nurse gathers data on growth and development, perception of self, and current health status. Perception is the basis for collecting and interpreting data, and communication verifies the accuracy of that perception.

Nursing diagnosis is developed from the assessment data, identifying the problems, concerns, and disturbances the patient is seeking help with.

Planning follows diagnosis. The nurse and the health care team build a care plan of interventions, setting goals and deciding on the means to achieve them, with the patient's participation encouraged. This is part of the transaction.

Implementation is the actual activities done to achieve the goals, the continuation of the transaction in this model.

Evaluation determines whether the goals were achieved and addresses the effectiveness of nursing care.

Analysis

The social systems portion of the open systems framework connects less clearly to goal attainment than the personal and interpersonal systems, and the individual's place within a social system is not clearly explained even though the social system encompasses other concepts in the theory. The model is dyadic, so it cannot be adapted to unconscious individuals. Multiple competing views and definitions of a single concept, such as power, blur the point for the reader.

Strengths

Nurses can grasp the theory and describe a logical sequence of events. Concepts are, for the most part, concretely defined and illustrated. King's definitions are clear and derived from the research literature, and her ten major concepts are easily understood, which establishes her work as important for knowledge building in nursing.

Weaknesses

The theory has been criticized for limited application where patients cannot interact competently with the nurse, though King maintained its broad use across most situations. Application to groups, families, or communities is underdeveloped. The theory also carries inconsistencies: King says nurses are concerned with groups' health care but concentrates on the dyadic relationship, and she calls nurse and client strangers while describing them working together toward goal attainment.

Conclusion

King advanced nursing knowledge with her conceptual system and middle-range Theory of Goal Attainment. By focusing on attaining goals through nurse-patient partnership, she gave nurses a system that has proven useful, and nurses worldwide continue to use her work to improve patient care.