Imogene M. King was born on January 30, 1923, in West Point, Iowa; died December 24, 2007, in St. Petersburg, Florida; and is buried in Fort Madison, Iowa. Imogene received a diploma in Nursing from St. John’s Hospital School of Nursing, St. Louis, Missouri, in 1945. While working in a variety of staff nurse roles, Imogene began course work toward a Bachelor of Science in Nursing Education, which she received from St. Louis University in 1948; she received a Master of Science in Nursing from St. Louis University in 1957. From 1947 to 1958, King worked as an instructor in medical-surgical nursing and was an assistant director at St. John’s Hospital School of Nursing. King went on to study with Mildred Montag as her dissertation chair at Teachers College, Columbia University, New York, receiving a Doctor of Education (EdD) in 1961.

From 1968 to 1972, King was the director of the School of Nursing at Ohio State University in Columbus. While at Ohio State, her book, Toward a Theory for Nursing: General Concepts of Human Behavior (1971), was published. In this early work, King concluded, “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” (1971, p. 129). Her book subsequently was awarded the American Journal of Nursing Book of the Year Award in 1973 (King, 1995a).

From 1961 to 1966, King was an assistant and associate professor of nursing at Loyola University in Chicago, where she developed a master’s degree program in nursing based on a nursing conceptual framework. Her first theory article appeared in 1964 in the Nursing Science journal with the nurse theorist, Dr. Martha Rogers, from New York University as the editor.

Between 1966 and 1968, King served as Assistant Chief of Research Grants Branch, Division of Nursing, in the U.S. Department of Health, Education, and Welfare, under Jessie Scott. While Imogene was in Washington, D.C., her article “A Conceptual Frame of Reference for Nursing” was published in Nursing Research (1968).

From 1968 to 1972, Imogene served as Director of the Nursing Department at Ohio State University. In 1980, King was awarded an honorary PhD from Southern Illinois University (Messmer, 2000).

King then returned to Chicago in 1972 as a professor in the Loyola University graduate program. She also served as the Coordinator of Research in Clinical Nursing at the Loyola Medical Center, Department of Nursing, from 1978 to 1980. In May 1998, King received an honorary doctorate from Loyola University, where her “Nursing Collection” is housed.

From 1972 to 1975, King was a member of the Defense Advisory Committee on Women in the Services for the U.S. Department of Defense. She also was elected alderman for a 4-year term (1975-1979) in Ward 2, Wood Dale, Illinois, in 1975.

In 1980, King was appointed professor at the University of South Florida, College of Nursing, in Tampa, Florida (Houser & Player, 2007). In 1981, the manuscript for her second book, A Theory for Nursing: Systems, Concepts, Process, was published. In addition to her first two books, she authored multiple book chapters and articles in professional journals, and a third book, Curriculum and Instruction in Nursing: Concepts and Process, was published in 1986. King retired in 1990 and was named professor emeritus at the University of South Florida and continued to guest lecture.

King continued to provide community service and to help plan care through her conceptual system and theory at various healthcare organizations, including Tampa General Hospital (Messmer, 1995). King never really retired, as she was always there for students, faculty, and colleagues who were using her theory, and even went “round the clock” to implement her theory at Tampa General Hospital. King also served on the nursing advisory board, and guest lectured at the University of Tampa.

In 1948, King joined the American Nurses Association (ANA) as a member of the Missouri Nurses Association and was active in Illinois and Ohio as well. Upon her move to Tampa, Florida, she became very active member in the Florida Nurses’ Association (FNA) and FNA District 4, Tampa. King held offices in various organizations, including President of the Florida Nurses Foundation, served on the FNA and the FNA District IV boards, and frequently was a delegate from the FNA to the ANA House of Delegates. In 1997, King received a gold medallion from Governor Chiles for advancing the nursing profession in the State of Florida. King was inducted into the FNA Hall of Fame and the ANA Hall of Fame in 2004. In 1994, King also was inducted into the American Academy of Nursing (AAN), served on the AAN Theory Expert Panel, and in 2005, was inducted as an AAN Living Legend. In 1996, King received the Jessie M. Scott Award at the ANA Convention. King was thrilled when Jessie Scott was there for the presentation, and she was on the floor of the ANA House of Delegates to hear President Clinton’s congratulations on ANA’s 100th anniversary and his admiration of his mother as a nurse anesthetist.

King was the keynote speaker for the 37th Annual Isabel Maitland Stewart Conference in Research in Nursing at Teachers College, Columbia University, in 2000 (Messmer & Fawcett, 2008; Messmer, 2008) and was very pleased when Mildred Montag came for her presentation. King was inducted into the Teachers College, Columbia University of Hall of Fame, in 1999. The King International Nursing Group (KING) was created to facilitate the dissemination and utilization of King’s conceptual system, the Theory of Goal Attainment, and related theories. Even after the organization became inactive, King consulted with members of the organization on an individual basis regarding her theory.

King was one of the original Sigma Theta Tau International (STTI) Virginia Henderson Fellows, and she received the STTI Elizabeth Russell Belford Founders Award for Excellence in Education in 1989 (Messmer, 2007). King was keynote speaker at two STTI theory conferences in 1992, and presented at multiple regional, national, and international STTI conferences on application of her theory.

King communicated regularly with undergraduate, graduate, and doctoral students who were learning about theories within her conceptual system. King served as advisor for Sieloff’s (1996) development of an instrument to measure the power of a nursing group within an organization, Killeen’s (1996) instrument to measure patient satisfaction with professional nursing care and Frey’s (1995) seminal work on adolescent patients diagnosed with type 1 diabetes.

King also was recognized as one of the early nurse theorists through her publications, Toward a Theory for Nursing (1971) and A Theory for Nursing: Systems, Concepts and Process (1981), which were translated into Japanese, Spanish, and German. In addition, Imogene authored numerous articles on her theory and served on the editorial board of Nursing Science Quarterly. King authored several chapters in various books, for example, 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).

King (1971) describes the purpose of her first book as follows:

King’s (1981) concepts are presented in the Major Concepts & Definitions box.

USE OF EMPIRICAL EVIDENCE

King (1971) spoke of concepts as “abstract ideas that give meaning to our sense perceptions, permit generalizations, and tend to be stored in our memory for recall and use at a later time in new and different situations” (pp. 11–12). King (1984) defined theory as “a set of concepts, which, when defined, are interrelated and observable in the world of nursing practice” (p. 11). Theory serves to build “scientific knowledge for nursing” (King, 1995b, p. 24). King (1971) provided the criteria to evaluate a theory focusing on “What research findings have been reported to verify the concepts or test the theoretical basis presented and is it useful in adding one’s understanding of the world and of the nursing discipline?” (p. 18).

King (1975a) identified at least two methods for developing theory as follows: (1) a theory can be developed and then tested in research, and (2) research can provide data from which a theory may be developed. King’s opinion (1978) was that, “in today’s world of building knowledge for a complex profession such as nursing, one must consider these two strategies.”

King cited many research studies in her 1981 book, especially regarding the development of her concepts. Within the personal system, King examined studies related to perception by Allport (1955), Kelley and Hammond (1964), Ittleson and Cantril (1954), and others. In developing her definition of space, King used studies from Sommer (1969) and Ardrey (1966) and noted Minckley’s (1968) research. For the concept of time, she acknowledged Orme’s (1969) work.

Within the interpersonal system, King presented communication theories and models, citing the studies of Watzlawick, Beavin, and Jackson (1967) and Krieger (1975). King examined studies by Whiting (1955), Orlando (1961), and Diers and Schmidt (1977) for information on interaction. King also noted Dewey and Bentley’s (1949) theory of knowledge, which addressed self-action, interaction, and transaction in Knowing and the Known, and Kuhn’s (1975) work on transactions.

Commenting on research existing at that time, particularly operations research regarding patient care, King (1975b) noted that “…most studies have centered on technical aspects of patient care and of the healthcare systems rather than on patient aspects directly.…Few problems have been stated that begin with what the patient’s condition demands or what the patient wants” (p. 9).

In her 1981 book, King further discussed that “several theoretical formulations about interpersonal relations and nursing process have been described in nursing situations” (pp. 151–152), citing studies by Peplau (1952), Orlando (1961), Paterson and Zderad (1976), and Yura and Walsh (1978) to support her ideas on the transactional process in her theory of goal attainment.

Developing the Conceptual System

In preparation of her 1971 book, King posed the following questions:

 What is the goal of nursing?

 What are the functions of nurses?

 How can nurses continue to expand their knowledge to provide quality care? (pp. 30, 39)

As a result of a review of 20 years of nursing literature (before 1971), King identified multiple concepts used by nurses to describe nursing. Figure 15-1 demonstrates the conceptual system that provided “one approach to studying systems as a whole rather than as isolated parts of a system” (King, 1995a, p. 18), and was “designed to explain (the) organized wholes within which nurses are expected to function” (1995b, p. 23).

King (1981) used a systems approach in the development of her conceptual systems and the middle range Theory of Goal Attainment. King noted that, “some scientists who have been studying systems have noted that the only way to study human beings interacting with the environment is to design a conceptual framework of interdependent variables and interrelated concepts” (King, 1981, p. 10). King (1995a) believed that her “framework differs from other conceptual schema in that it is concerned not with fragmenting human beings and the environment but with human transactions in different kinds of environments” (p. 21).

“An awareness of the complex dynamics of human behavior in nursing situations prompted [King’s] formulation of a conceptual framework that represents personal, interpersonal, and social systems as the domain of nursing” (King, 1981, p. 130). Each of the three systems identified human beings as the basic element in the system, thus “the unit of analysis in [the] framework [was] human behavior in a variety of social environments” (King, 1995a, p. 18). Individuals exist within personal systems, and King provided an example of a total system as being a patient or a nurse. King believed that it is necessary to understand the concepts of body image, growth and development, perception, self, space, and time to comprehend human beings as persons.

Interpersonal systems are formed when two or more individuals interact, forming dyads (two people) or triads (three people). The dyad of a nurse and a patient is one type of interpersonal system. Families, when acting as small groups, also can be considered interpersonal systems. Comprehension of the interpersonal system requires an understanding of the concepts of communication, interaction, role, stress, and transaction.

A comprehensive interacting system consists of groups that make up society, and is referred to as a social system. Religious, educational, and healthcare systems are examples of social systems. The influential behavior of an extended family on an individual’s growth and development in society is another example of the influence of a social system. Within a social system, the concepts of authority, decision making, organization, power, and status are essential for system understanding.

“The concepts in the framework are the organizing dimensions and represent knowledge essential for understanding the interactions between the three systems” (King, 1995a, p. 18). Concepts were placed in the personal system because they primarily related to individuals, whereas concepts were placed in the interpersonal system because they “emphasized interactions between two or more persons” (King, 1995a, p. 18). Concepts were placed in the social system because they “provided knowledge for nurses to function in larger systems” (King, 1995a, p. 18). However, King (1995a) clearly identified that “the concepts in the framework are not limited to only one of the dynamic interacting systems but cut across all three systems” (p. 19).

King’s Middle Range Theory of Goal Attainment

In 1981, King derived the middle range Theory of Goal Attainment from her conceptual system. The question that motivated King to develop a theory was, “What is the nature of nursing?” (King, 1995b, p. 25). She answered, “the way in which nurses, in their role, do with and for individuals that differentiates nursing from other health professionals” (King, 1995b, p. 26). This question and answer guided her development of the Theory of Goal Attainment.

King (1995b) used the following criteria to develop the theory:

 “What are the philosophical assumptions?”

 “Are the concepts clearly identified and defined?”

 “Are the concepts related in propositional statements or models?”

 “Does the theory generate questions to be answered, or hypotheses to be tested in research, to generate knowledge and affirm the theory?”

“The human process of interactions formed the basis for designing a model of transactions that depicts theoretical knowledge used by nurses to help individuals and groups attain goals” (1995a, p. 27) (Figure 15-2).

King (1995b) stated the following:

“Mutual goal setting [between a nurse and a client] is based on (a) nurses’ assessment of a client’s concerns, problems, and disturbances in health; (b) nurses’ and clients’ perceptions of the interference; and (c) their sharing of information whereby each functions to help the client attain the goals identified. In addition, nurses interact with family members when clients cannot verbally participate in the goal setting” (p. 28).

To test her theory, King (1981) conducted research, identifying that her study varied from previous studies in that it “described the nurse-patient interaction process that leads to goal attainment” (p. 153). King’s research described a process that led to goal attainment and studied nurse-patient interactions to determine whether nurses made transactions. King used a method of nonparticipant observation to collect information about nurse-patient interactions on a patient care unit in a hospital setting. Patients and nurses volunteered to participate in the study. King then trained graduate students in the nonparticipant observation technique before collecting data. She examined multiple interactions and recorded verbal and nonverbal behaviors as raw data. King also developed a goal-oriented nursing record that nurses could use to determine if they were making transactions leading to goal attainment (King, 1981, pp. 163-177).

MAJOR ASSUMPTIONS

King’s personal philosophy about human beings and life influenced her assumptions, including those related to the environment, health, nursing, individuals, and nurse-patient interactions. King’s conceptual system and Theory of Goal Attainment are “based on an overall assumption that the focus of nursing is human beings interacting with their environment, leading to a state of health for individuals, which is an ability to function in social roles” (King, 1981, p. 143).

THEORETICAL ASSERTIONS

King’s Theory of Goal Attainment (1981) focuses on the interpersonal system and the interactions that take place between individuals, specifically in the nurse-patient relationship. In the nursing process, each member of the dyad perceives the other, makes judgments, and takes actions. Together, these activities culminate in reaction. Interaction results and, if perceptual congruence exists and disturbances are conquered, transactions occur. The system is open to permit feedback because each phase of the activity potentially influences perception.

King (1981) developed eight propositions in her Theory of Goal Attainment. These propositions are detailed in Box 15-1 and describe the relationships between concepts. Diagrams follow each proposition. When the propositions were analyzed, 23 relationships were not specified; 22 relationships were positive, and no relationship was negative (Austin & Champion, 1983) (Figure 15-3). In addition, King (1981) derived seven hypotheses from the Theory of Goal Attainment, which are found in A Theory for Nursing: Systems, Concepts, Process.

Box 15-1   Propositions Within King’s Theory of Goal Attainment

1. If perceptual congruence (PC) is present in nurse-client interactions (I), transactions (T) will occur.

2. If nurse and client make transactions (T), goals will be attained (GA).

3. If goals are attained (GA), satisfactions (S) will occur.

4. If goals are attained (GA), effective nursing care (NC_e) will occur.

5. If transactions (T) are made in nurse-client interactions (I), growth and development (GD) will be enhanced.

6. If role expectations and role performance as perceived by nurse and client are congruent (RCN), transactions (T) will occur.

7. If role conflict (RC) is experienced by nurse and client or both, stress (ST) in nurse-client interactions (I) will occur.

8. If nurses with special knowledge and skills communicate (CM) appropriate information to clients, mutual goal setting (T) and goal attainment (GA) will occur. [Mutual goal setting is a step in transaction and thus has been diagrammed as transaction.]

From Austin, J. K., & Champion, V. L. (1983). King’s theory of nursing: Explication and evaluation. In P. L. Chinn (Ed.), Advances in nursing theory development (p. 55). Rockville, MD: Aspen. Aspen

LOGICAL FORM

In the initial framework suggested in her 1968 article, King identified the following four comprehensive concepts that center on human beings:

King viewed individuals as open systems with energy exchange taking place within, and external to, human beings. Although King’s original framework was abstract and dealt with “only a few elements of concrete situations” (King, 1981, p. 128), King believed that her four “universal ideas (social systems, health, perception, and interpersonal relations) were relevant in every nursing situation” (King, 1981, p. 128).

Later, King (1975a) identified that her “personal approach to synthesizing knowledge for nursing was to use data and information available from (1) research in nursing and related fields, and (2) 25 years in active practice, teaching, and research. From all the knowledge available, a theoretical framework, relevant for nursing, was formulated” (p. 36). In 1978, King indicated that theory development is composed of inductive and deductive reasoning, with theory’s primary purpose being the generation of knowledge through research.

King (1981) then began further development of her conceptual system and proposed the middle range Theory of Goal Attainment to describe “the nature of nurse-client interactions that lead to achievement of goals” (p. 142) as follows:

In her 1981 publication, King spoke of fewer dichotomies between health and illness, referring to illness as interference in the life cycle. Through reformulation, King provided a more open system relationship between person and environment. King also revised her terminology, using adjustment instead of adaptation, and person, human being, and individual rather than man.

A logical progression of development existed in the conceptual system from 1971 to 1981, with King deriving her middle range Theory of Goal Attainment from her conceptual system. The Theory of Goal Attainment “organize[s] elements in the process of nurse-client interactions that result in outcomes, that is, goals attained” (King, 1981, p. 143).

King (1971) initially had stated the following:

During a 1978 nursing theorist conference, King indicated that if nurses were taught this process, they could begin to predict outcomes in nursing. Later, in 1981, King added, “this theory should serve as a standard of practice related to nurse-patient interactions and is, in this sense, a normative theory” (p. 145). Clements and Roberts (1983) expanded on these ideas to show the process of the Theory of Goal Attainment in relation to various nursing situations, including the health of families.

King’s (1971) early publication led to nursing curriculum development and practice application at Ohio State and other universities. In her 1981 book, King identified that “theory, because it is abstract, cannot be immediately applied to nursing practice or to concrete nursing education programs. When empirical referents are identified, defined and described, …theory is useful and can be applied in concrete situations” (p. 157). However, “knowledge of the concepts can be applied in concrete situations” (p. 41).

Professionals in most nursing specialty areas have used the concepts of King’s (1981) Theory of Goal Attainment in nursing practice. Its relationship to practice is obvious because the nurse functions primarily through interactions with individuals and groups within the environment. Even before King’s conceptual system was published, Brown and Lee (1980) stated “this proposed intrasystems model provides an approach for stimulating continued learning, for establishing innovative foundations for nursing practice, and for generating inquiry through research” (p. 469). King (1984) believes that “nurses, who have knowledge of the concepts of this Theory of Goal Attainment, are able to perceive what is happening to patients and family members and are able to suggest approaches for coping with the situations” (p. 12).

King also developed a documentation system, the goal-oriented nursing record (GONR), to accompany the middle range Theory of Goal Attainment, and to record goals and outcomes. The GONR is a method of collecting data, identifying problems, and implementing and evaluating care that has been used effectively in patient settings. The theory and the GONR are useful in practice, because nurses have the ability to provide individualized plans of care while encouraging active participation from patients in the decision-making phase (King, 1984). Nurses also can use the GONR approach to document the effectiveness of nursing care. “The major elements in this record system are: (a) data base, (b) nursing diagnosis, (c) goal list, (d) nursing orders, (e) flow sheets, (f) progress notes, and (g) discharge summary” (King, 1995b, pp. 30-31).

Healthcare professionals have implemented King’s (1981) conceptual system and middle range Theory of Goal Attainment in various national and international practice settings (King, 2006, 2007). The following briefly identifies some of these settings, and the references detail additional settings. Jolly and Winker (1995) described the application of the Theory of Goal Attainment within the context of nursing administration. Alligood (1995) applied the Theory of Goal Attainment to adult patients within orthopedic nursing settings. Laben, Sneed, and Seidel (1995) used goal attainment in short-term group psychotherapy. Coker and colleagues (1995) used the conceptual system to implement nursing diagnoses in a Canadian community hospital, and Fawcett, Vaillancourt, and Watson (1995) used the conceptual system within a large Canadian tertiary care hospital. Viera and Rossi (2000) used King’s conceptual system to study nursing diagnoses with puerperal women. Williams (2001) applied King’s work in emergency and rural nursing. The Theory of Goal Attainment provided the framework for Daniel’s (2002) descriptive study of the perceptions of young adults with chronic inflammatory bowel disease.

In addition to application of the Theory of Goal Attainment with individual or groups of patients or clients, King’s conceptual system has been applied to nursing practice. In 1989, Elberson described how King’s conceptual system could be applied to nursing administrative practice. Sieloff (1995b) defined the health of a social system. Sieloff began to develop a middle range theory of group power within organizations in 1989. King’s theory was further refined and revised (1995a, 2007). Olsson and Forsdahl (1996) examined the role of the new nurse in a Norwegian hospital. King (2007) further clarified the application of her conceptual system within a healthcare organization.

Previous publications have obviously supported the acceptance of King’s work in the nursing community. Frey, Sieloff, and Norris (2002) provided an overview of the impact of King’s work in the past, present, and future. The acceptance of King’s work in the future was further supported by several other publications. King (2007) described her theory of goal attainment and the transaction process as viewed in the twenty-first century. Lane-Tillerson (2007) emphasized that “the idea of continuous advancement is central to Imogene King’s (1981) conceptual framework” (p. 141), and imagined nursing practice in 2050, using King’s conceptual system, providing support that King’s work will be accepted by the nursing community in the years to come. Khowaja (2006) described the use of King’s conceptual system and Theory of Goal Attainment (1981) in the development of a clinical pathway. Killeen and King (2007) provided additional support and addressed the use of King’s conceptual system with nursing informatics and nursing classification systems for global communications.

Education

Nursing faculty at several universities, such as King and Daubenmire (1973) at Ohio State University; Gold, Haas, and King (2000) at Loyola University in Chicago; and Gulitz and King (1988) at the University of South Florida used King’s concepts to design curricula in nursing programs. In 1980, Brown and Lee reported that King’s concepts were useful in developing a framework for “use in nursing education, nursing practice, and for generating hypotheses for research … [They] provide a systematic means of viewing the nursing profession, organizing a body of knowledge for nursing, and clarifying nursing as a discipline” (p. 468). King’s conceptual system and theory also have application for nursing education internationally as described by Rooke (1995b) for a Swedish educational setting and Bello (2000) for Portuguese undergraduate students.

The literature also includes the application of King’s work to patient education. Palmer (2006) identified patient education implications for nurses working with older adults.

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