Nurses are the key persons in the health care system who identify the goals and the means to help individuals and families attain goals.
The author and editor wish to thank Maureen A. Frey who authored this chapter in previous editions of this text.
History and Background
In the mid-1960s, Imogene King wrote of the need for focus, organization, and use of a nursing knowledge base (King, 1968). She proposed that knowledge for nursing resulted from the systematic use and validation of knowledge about concepts relevant to nursing situations. The use of knowledge in critical thinking results in decisions that are implemented in professional nursing practice.
In 1971, King proposed a conceptual system for nursing around four concepts she considered universal to the discipline of nursing: social systems, health, perception, and interpersonal relationships. These areas were identified from the synthesis and reformulation of concepts using inductive and deductive reasoning, critical thinking, and extensive review of nursing and literature from other health-related disciplines. Concepts were organized around individuals as personal systems, small groups as interpersonal systems, and larger social systems such as community and school (King, 1971). Role, status, social organization, communication, information, and energy were identified as basic concepts of functions of systems. King proposed that concepts were interrelated and could be used across systems to identify the essence of nursing.
King expanded the conceptual system during the 1970s by further explicating the nature of persons and environment, strengthening the general systems orientation, and expanding the concepts. A more formalized conceptual system of personal, interpersonal, and social systems was presented in 1981. Concepts in the personal system were perception, self, growth and development, body image, time, and space. Concepts in the interpersonal system were human interaction, communication, transactions, role, and stress. Concepts in the social system were organization, authority, power, status, and decision making.
Also presented in the 1981 text was the Theory of Goal Attainment, derived from the personal and interpersonal systems and a process model of human interactions. The Theory of Goal Attainment specifically addresses how nurses interact with patients to achieve health goals. The initial concepts of the theory (perception, communication, interaction, transaction, self, role, and decision making) represented the essence of nursing (King, 1981, 2006a,b). The model of human interaction defines the observable behaviors in nurse-patient interactions that lead to transactions.
Although no major changes were made to the conceptual system or Theory of Goal Attainment since A Theory for Nursing: Systems, Concepts, Process, King provided clarification, explanation, and some additional concepts up until her death in 2007. The concepts of learning and coping were added; the concept of space was redefined as personal space; and the concept of stress was expanded to include stressors (King, 1990, 1991, 2008). King explicated the philosophical basis and enduring nature of the conceptual system and theory for nursing with emphasis on the twenty-first century and the world as community (Fawcett, 2001; King, 1990, 1994, 1995a,b, 1996, 1997, 1999, 2006a, 2006b, 2007, 2008). Contemporary themes and applications include information systems, nursing diagnoses, technological advances, changes in organization and delivery of health care for individuals and families (Alligood, 2010; Fewster-Thuente & Velsor-Friedrich, 2008; Frey & Sieloff, 1995; Gianfermi & Buchholz, 2011; Killeen & King, 2007; Sieloff & Frey, 2007; Sieloff, Killeen, & Frey, 2010; Sieloff & Messmer, 2010). In addition, others have extended the conceptual system by developing and testing middle-range theories (Alligood, 2007; Doornbos, 2007; duMont, 2007; Ehrenberger, Alligood, Thomas, et al., 2007; Fairfax, 2007; Frey, 1995; Hernandez, 2007; Kameoka, Funashima, & Sugimori, 2007; Killeen & King, 2007; May, 2007; Reed, 2007; Shartz-Hopko, 2007; Sieloff, 2007; Sieloff & Bularzik, 2011; Walker & Alligood, 2001; Wicks, Rice, & Talley, 2007; Zurakowski, 2007). Practice applications are numerous and cross all health care settings, age groups, and diagnoses (Sieloff, Killeen, & Frey, 2010). Overall, King’s conceptual system and Theory of Goal Attainment represent significant theoretical structures for theory development and theory-based practice for nursing.
Overview of King’s Conceptual System and Theory of Goal Attainment
King’s conceptual system is based on the assumption that human beings are the focus of nursing. The goal of nursing is health promotion, maintenance, and/or restoration; care of the sick or injured; and care of the dying (King, 1992). King (1996) states that, “nursing’s domain involves human beings, families, and communities as a framework within which nurses make transactions in multiple environments with health as a goal” (p. 61). The linkage between interactions and health is behavior, or human acts. Nurses must have the knowledge and skill to observe and interpret behavior and intervene in the behavioral realm to assist individuals and groups cope with health, illness, and crisis (King, 1981). Concepts gleaned from an extensive review of the nursing literature organize knowledge about individuals, groups, and society (King, 1971, 1992). King notes that the concepts are often interrelated and can be applied across systems. According to King (1981, 1988, 1991), concepts are critical because they provide knowledge that is applicable to practice. Systems and concepts within King’s conceptual system and Theory of Goal Attainment are described and defined in the following section.
Individuals are personal systems (King, 1981). Each individual is an open, total, unique system in constant interaction with the environment. Interactions between and among personal systems are the focus of King’s conceptual system. Patients, family members, friends, other health care professionals, clergy, and nurses are just a few examples of individuals who interact in the nursing practice environment. The following concepts provide foundational knowledge that contributes to understanding individuals as personal systems:
• Self: King (1981) cites developmental psychologist’s A. T. Jersild’s (1952) definition of self when explaining that “knowledge of self is a key to understanding human behavior because self is the way I define me to myself and to others. Self is all that I am. I am a whole person. Self is what I think of me and what I am capable of being and doing. Self is subjective in that it is what I think I should be or would like to be” (p. 26). Self is a dynamic, action-oriented open system.
• Learning: “A process of sensory perception, conceptualization, and critical thinking involving multiple experiences in which changes in concepts, skills, symbols, habits, and values can be evaluated in observable behaviors and inferred from behavioral manifestation” (King, 1986, p. 24).
• Coping: King (1981) used the term coping in her discussion of the concept of stress in the interpersonal system and in later discussions of the Theory of Goal Attainment (King, 1992, 1997) without explicit definition.
Interpersonal systems are formed by the interactions of two or more individuals (King, 1981). As the number of individuals increases, so does the complexity of the interaction. These groups may range in size from two or three interacting individuals to small or large groups. King’s process of nursing occurs primarily within the interpersonal systems between the nurse and patient. Concepts critical to understanding interactions between individuals are defined as follows:
• Interaction: “Acts of two or more persons in mutual presence” (King, 1981, p. 85). “The process of interactions between two or more individuals represents a sequence of verbal and nonverbal behaviors that are goal-directed” (King, 1981, p. 60).
• Stress: “Dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance which involves an exchange of energy and information between the person and the environment for regulation and control of stressors” (King, 1981, p. 98).
• Transaction: “Observable behaviors of human beings interacting with their environment” (King, 1981, p. 147). “In the interactive process, two individuals mutually identify goals and the means to achieve them. When they agree to the means to implement the goals, they move toward transactions…. Transactions are defined as goal attainment” (King, 1981, p. 61).
Social systems are composed of large groups with common interests or goals. A social system is defined as “an organized boundary system of social roles, behaviors, and practices developed to maintain values and the mechanisms to regulate the practice and rules” (King, 1981, p. 115). Examples of social systems include health care settings, workplaces, educational institutions, religious organizations, and families (King, 1981). Interactions with social systems influence individuals throughout the life span. Concepts that are useful to understand interactions within social systems and between social and personal systems are defined as follows:
• Authority: “Transactional process characterized by active, reciprocal relations in which members’ values, backgrounds, and perceptions playa role in defining, validating, and accepting the [directions] of individuals within an organization” (King, 1981, p. 124).
• Decision making: “Dynamic and systematic process by which a goal-directed choice of perceived alternatives is made, and acted upon, by individuals or groups to answer a question and attain a goal” (King, 1981, p. 132).
King’s conceptual system provides both structure and function for nursing. Clearly stated assumptions about persons, environment, health, nursing, and systems provide a conceptual orientation of holism and dynamic interaction, specify health as the goal of nursing, and actively include the patient (individual, family, or community) in decisions about setting goals and the behavior necessary to achieve health goals.
Theory of Goal Attainment
The Theory of Goal Attainment addresses nursing as a process of human interaction. Indeed, King (1981) stated that the Theory of Goal Attainment is a normative theory; that is, it should set the standard of practice for all nurse-patient interactions. King (1997) recalled finding an index card on which she had written the following 15 years previously: “King’s law of nurse-patient interaction: Nurses and patients in mutual presence, interacting purposefully, make transactions in nursing situations based on each individual’s perceptions, purposeful communication, and valued goals” (p. 184).
The nurse and patient form an interpersonal system in which each affects the other and in which both are affected by situational factors in the environment. Drawn from both the personal and interpersonal system concepts, the Theory of Goal Attainment comprises the concepts of perception, communication, interaction, transaction, self, role, growth and development, stress/stressors, coping, time, and personal space. King (1981, 1991) identified that perception, communication, and interaction are essential elements in transaction. When transactions are made, goals are usually attained. The human interaction and conceptual focus dimensions of the theory guide the nursing process dimension (Figure 9-1).
King demonstrated linkages between the Theory of Goal Attainment and the traditional nursing process as shown in Table 9-1 (King, 1992). King (1993) viewed the traditional nursing process as a system of interrelated actions—the method by which nursing is practiced. In contrast, knowledge of the interrelated concepts in the Theory of Goal Attainment (King, 1992) provides the theoretical basis for nursing practice. King (1995b) underscored the importance of nursing process as both method and theory when she stated, “Nurses are first, and foremost, human beings who perform their functions in a professional role. It is the way in which nurses, in their role, do with and for individuals that differentiates nursing from other health professionals” (p. 26). In this way, King illustrated how “nursing theory serves to connect philosophical reflection with nursing practice” (Whelton, 2008, p. 79).
|Nursing Process as Method∗||Nursing Process as Theory†|
|A system of interrelated actions||A system of interrelated concepts|
|Assess||Perception of nurse and client|
|Communication of nurse and client|
|Interaction of nurse and client|
|Plan||Decision making about goals|
|Agree to means to attain goals|
|Evaluate||Goal attained (if not, why not?)|
From King, I. M. (1992). King’s theory of goal attainment. Nursing Science Quarterly, 5(1), 23, with permission from Sage Publications.
Critical Thinking in Nursing Practice with King’s Conceptual System
It is generally agreed that critical thinking is knowing how to think, how to apply, how to analyze, how to synthesize, and how to evaluate. Whereas the traditionalnursing process of “assess, plan, implement, and evaluate” provides a method, the critical thinking process emphasizes the intellectual skills of apprehension, judgment, and reasoning.
Rubenfeld and Scheffer (1999) conducted a study to define critical thinking in nursing. They formulated the following consensus statement to reflect the essence of critical thinking in nursing:
Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating information seeking, logical reasoning, predicting, and transforming knowledge (Rubenfeld & Scheffer, 1999, p. 5).
The development and use of critical thinking in nursing has received considerable attention both in nursing education and in practice over the past two decades. However, critical thinking has always been an integral component in King’s perspective of nursing. In an early publication, Daubenmire and King (1973) presented a diagram (Figure 9-2) titled “Methodology for the Study of Nursing Process.” Critical thinking is illustrated by the use of terms such as analyze, synthesize, verify, and interpret. King explicitly linked critical thinking to the mental acts of judgment that are implicit in perception, communication, and interactions leading to transaction (King, 1992) and the concept of decision making (King, 1999). Later, King (1999) added that ethical theories and principles, along with the nursing process, had structured critical thinking and its pedagogy in most nursing programs.
The delivery of nursing care to patients involves a process of thinking as well as doing. In contrast to the traditional nursing process as a system of interrelated actions, King’s perspective of the process reflects the science of nursing. Critical thinking provides the rationale for actions taken by the nurse and serves as an excellent fit with the premises of this text.
The following discussion illustrates critical thinking questions based on concepts within King’s systems framework that are essential in carrying out activities of assessing, planning, implementing, and evaluating.
At the first step of King’s process of nursing, the nurse meets the patient and communicates and interacts with him or her. Assessment is conducted by gathering data about the patient based on relevant concepts. The nurse considers the following questions: