PROPOSITIONS

Propositions of Kings Goal Attainment Theory as adapted from the book of Alligood and Tomey:

If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur. If nurse and client make transaction, goal will be attained If goals are attained, satisfaction will occur If transactions are made in nurse-client interactions, growth & development will be enhanced If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.

The theory of Imogene Kings starts with a person who has a health need which can be classified into three: 1.) need for health information which is usable, 2.) need for care that seeks to prevent illness and 3.) need for care when human beings are unable to help themselves (King in George, 1995, p.221). The persons perception of his need is affected by several factors like his awareness of his existence, growth and development, body-image and learning (Alligood and Tomey, 2002). His goal is to satisfy his need and for him to be able to fulfill it, he has to ask for help from other sources. He can ask from a nurse or anyone from his environment. When he communicates with a nurse or another person, the perceptions of these people towards his need are also affected by the elements that are also present in him. Through verbal and non-verbal means, an interaction is being made between the person and the nurse (Anonuevo, et. al, 2000) . The environment, according to King, is essential for achieving goals due to its material and human resources (King in George, 1995, p.221) and therefore, the person also interacts with the environment. The interaction of the person and the nurse is goal-directed (King in George, 1995, p.217) and through this, both parties reach a common and accurate perception of the problem and means are explored on how to resolve it. After the means exploration, goal-setting is made which is subject for agreement. Finally, transaction happens when the agreed goals are

acted upon and necessary actions are taken to achieve them. Finally, if the goals are attained, satisfaction will occur and the health need fulfilled. In a figure the group created, the Goal Attainment Theory of King is likened to a sling shot (see figure below). The frame is the person who has a health need. For him to achieve his health need, he communicates his perception of his need with a nurse (another person) and to the elements of the environment. His perception is affected by several factors like his learning and growth and development as stated by Araceli Ocampo Balabagno in the N207 module. With his communication to the nurse and the environment, their perceptions are also influenced by the same factors that have affected him in the establishment of his perception. Through interaction, an accurate representation of his perception is realized by the nurse and the environment where means to explore the goal are discovered. The person in his connection with the nurse in particular, reaches a goal which is mutuallyagreed upon by parties involved. In the sling shot, the pocket where the stone is placed, serves as the area for transaction. It will only happen if the person executes the steps planned together with the nurse. In the case of the figure, transaction happens when the person uses the sling shot to propel the stone to hit the target (goal) which makes goal attainment possible.

The theory of goal attainment was first introduced by Imogene King in the early 1960s. The theory describes a dynamic, interpersonal relationship in which a person grows and develops to

attain certain life goals. To better understand the theory let us first read on the Metaparadigm in Nursing according to Imogene King.

Imogene King Goal Attainment Theory: Metaparadigm in Nursing

1. Person: Imogene King described a person existing in an open system as a spiritual being and rational thinker who makes choices, selects alternative courses of action, and has the ability to record their history through their own language and symbols, unique, holistic and have different needs, wants and goals. According to Imogene King, human being has three fundamental needs: a. The need for the health information that is unable at the time when it is needed and can be used b. The need for care that seek to prevent illness c. The need for care when human beings are unable to help themselves. 2. Health : According to Imogene King, health involves dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of ones resources to achieve maximum potential for daily living. 3. Environment : It is the background for human interactions. It involves: a. Internal environment transforms energy to enable person to adjust to continuous external environmental changes. b. External environment involves formal and informal organizations. hurse is a part of the patients environment. 4. Nursing: Nursing for Imogene King is an act wherein the nurse interacts and communicates with the client. The nurse helps the client identify the existing health condition, exploring and agreeing on activities to promote health. The goal of the nurse in Imogene Kings theory is to help the client maintain health through health promotion and maintenance, restoration, and caring for the sick and dying.

Imogene King Goal Attainment Theory: Interacting Systems Framework

Imogene King proposed that the nurse interacts in the system simultaneously at three different levels, namely Personal, Interpersonal, and Social Frameworks. These levels are independent and at the same time co-exist to influence over-all nursing practice. Personal- how the nurse views and integrates self based from personal goals and beliefs. Interpersonal - how the nurse interrelates with co-worker or patient particularly in a nursepatient relationship. Social - how the nurse interacts with co-workers, superiors, subordinates and the client environment in general.

Propositions of Imogene Kings Theory of Goal Attainment

From the theory of goal attainment Imogene King developed predictive propositions, which includes:

If perceptual interaction accuracy is present in nurse-patient interactions, a transaction will happen. If nurse and client make transaction, goal will be attained. If goal are attained, satisfaction will occur. If goals are met, efficient nursing care will happen. If transactions are made in nurse-client interactions, growth and development will be enhanced

If role expectations and role performance as perceived by nurse and client are congruent, transaction will occur. If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur If nurse with special knowledge and skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.

Goal Attainment Theory Theory of goal attainment was first introduced by Imogene King in the early 1960s. Theory describes a dynamic, interpersonal relationship in which a person grows and develops to attain certain life goals. Factors which affect the attainment of goal are: roles, stress, space & time From the theory of goal attainment king developed predictive propositions, which includes: If perceptual interaction accuracy is present in nurse-client interactions, transaction will occur If nurse and client make transaction, goal will be attained If goal are attained, satisfaction will occur If transactions are made in nurse-client interactions, growth & development will be enhanced If role expectations and role performance as perceived by nurse & client are congruent, transaction will occur If role conflict is experienced by nurse or client or both, stress in nurse-client interaction will occur If nurse with special knowledge skill communicate appropriate information to client, mutual goal setting and goal attainment will occur.
Many people believe King's theory of goal attainment to be a productive and empowering way for nurses and patients to interact. There has been some discussion about how well the theory applies across all groups of patients, as it is necessary for the patient to be able to interact with the nurse to develop and agree on goals, and on ways to work toward those goals. Others contend that King's theory can be applied to all groups because a large portion of communication involves nonverbal behavior, so being able to communicate through spoken language is not a prerequisite for transactions to occur.

Goal Attainment Theory Conceptual Framework It includes: Several basic assumptions Three interacting systems Several concepts relevant for each system Basic assumptions Nursing focus is the care of human being. Nursing goal is the health care of individuals & groups.

Human beings: are open systems interacting constantly with their environment. Interacting systems: Personal system, Interpersonal system, Social system Concepts are given for each system : o Concepts for Personal System: Perception, Self, Growth & development, Body image, Space, Time o Concepts for Interpersonal System: Interaction, Communication, Transaction, Role, Stress o Concepts for Social System: Organization, Authority, Power, Status, Decision making
The theory of goal attainment, which lies at the heart of King's theory of nursing, exists in the context of her conceptual framework. The essence of goal attainment theory is that the nurse and the patient work together to define and reach goals that they set together. The patient and nurse each perceive, judge, and act, and together the patient and nurse react to each other and interact with each other. At the end of this process of communication and perceiving, if a goal has been set a transaction is said to have occurred. The nurse and patient also decide on a way to work toward the goal that has been decided upon, and put into action the plan that has been agreed upon. King believes that the main function of nursing is to increase or to restore the health of the patient, so then, transactions should occur to set goals related to the health of the patient. After transactions have occurred and goals have been defined by the nurse and patient together, both parties work toward the stated goals. This may involve interactions with other systems, such as other healthcare workers, the patient's family, or larger systems. After the transaction has occurred, and the goal has been set, King believes that it is important for good documentation to be practiced by the nurse. She believes that documenting the goal can help to streamline the process of goal attainment, making it easier for nurses to communicate with each other and other healthcare workers involved in the process. It also helps to provide a way to determine if the goal is achieved. This assessment of whether or not the goal has been successfully achieved plays an important end stage in King's goal attainment theory.

Theoretical Framework

Dynamic Interacting System

The essence of Goal Attainment Theory is for the nurse to promote health by using initially the nurse's personal system. It begins with self-awareness of all the components of his personal self. It is only after self awareness that the nurse will be effective in the assessment of the client. The nurse then interacts with the client and begins communicating. Upon communicating, the interpersonal system will then exist, which is basically the overlap of

the personal system of the nurse and the client. It is imperative then that the nurse has a solid awareness of himself before communicating with the client so that the interpersonal system will be created in a sense that the nurse provides confidence to the care that he will be providing. The Social System then builds up from the interaction that was created. It is where clear and distinct roles will be defined and the client will realize that he is a patient who, with his actions; permitted himself to be in an institution that has the same goal as what he wants. The client wants to get well or be healthy that is why he is in a caring institution (e.g. hospital, clinic, etc) where he has to follow certain rules as well as to communicate his needs to the nurse; which is a part of the caring social system. It is then when transaction occurs; which is the process of purposeful, goal-directed interaction with the environment to achieve mutually acceptable goals.

APPLICATION FROM THEORY TO PRACTICE

Imogene Kings Goal Attainment Theory in Application to the Care of the Elderly in the Emergency Room Situation: An 80-year-old female patient came in the Emergency Room lying on a stretcher. She was brought to the hospital by her son because she was no longer responding to verbal stimulations. She had a nasogastric tube because she is no longer capable of feeding orally. Upon assessment, we found out that she responded to pain stimulation. Her vital signs were BP-140/60, RR-25, PR-108 and T- 38.2. The patients Glasgow Comma Scale was 8. Application of Imogene Kings Theory In this situation, the patient can no longer speak or decide for herself, so her son can provide the necessary information and decisions for both of us to formulate goals that are necessary for the patients care and later on act on them. Through proper interaction and effective communication with the patients son, we were able to understand each others ideas and concerns and we came up with the goals (for their time being at the ER) : to stabilize the patients situation, preserve the patients integrity and carry out necessary laboratory examinations to know the underlying cause of the patients current problem. In the care of my elderly patient, I was very careful with the procedures that I executed especially with the invasive ones such as IV insertion, since elderly patients are very susceptible to infection. Through this, I can prevent doing further harm to her. I then promoted an environment where I maintained the patients integrity through providing her physiologic needs. I also interacted with the patient despite the fact that she

is unconscious because I believe that by doing such, I acknowledge and respect the value of my client. Not only that, I allowed her significant others to be involved in the assessing, planning and execution of the plan of care for the patient. After carefully assessing the status of my client, interacting with his son and formulating goals, I started deliberating on what nursing procedures are best for the patient while at the emergency room. So I decided to carry out the physicians orders (medications, laboratories, IV fluids, etc.). Then I promoted a safe and clean environment for the patient. And since the patient can no longer provide her basic physiologic needs, I fed her via the nasogastric tube and changed her diapers and clothing to maintain her bodys integrity despite her disability. I also allowed her son to participate in the planning and intervention so that she may feel loved and well taken cared of. After 3 hours of attending to the patient at the Emergency Room, the patients vital signs were stable, the laboratory examinations necessary for knowing the clients status were executed, and the patient was transported safely to the ward department. I then endorsed the care of my patient to the ward nurse.

Imogene Kings Goal Attainment Theory in Application to the Primary Health Care setting Imogene King's model is a model of three interacting systems: personal, interpersonal, and social. In her theory of goal attainment, she states that client goals are met through the transaction between nurse and client. The model can be applied to all settings. King describes her model as a conceptual system and the goal of nursing as bringing a person closer to a healthy state (King, 1997, 2001). The nurse and the person interact toward a goal. The end-point of this interaction, which occurs over time, is transaction, at which the person's goal is met. Working as a staff nurse in a Primary Health Center, Imogenes theory is realized through the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space with our patients. Most of them are for regular check-up and follow ups which give us opportunity to plan nursing care and set goals to be achieved by the patients for a certain period of time. Middle-East countries especially gulf area are known to have one of the highest mortality and morbidity rates in Diabetes. Most of them are obese, non-working, and has inactive lifestyle. Diabetic patients are carefully managed in our diabetic clinic. Each of them are given monthly appointments to follow up with the nurse and the doctor to evaluate the care that is planned both by the nurse and the patient to establish a controlled blood sugar, prevent diabetic foot and engage patients in healthy lifestyle. Patients are encouraged and motivated to participate in the care of plan that is most comfortable with them and most importantly within the norms of their society and acceptable to their culture and tradition. They are usually taught to self-inject themselves with insulin or a family member is asked and taught to give insulin to the patient. Patient or a family member is also taught to check and record the blood sugar everyday and to keep a record about the food that the patient has eaten. During their monthly appointment we evaluate all that is taught to the patient and revise everything if it is important and necessary for

the health of the patient or we refer them to Hamad General Hospital if it is deemed necessary. Each of them has a registration book where we document everything and where all records are kept. Patients are involved and empowered in a way that they get to have a chance to participate in deciding the plan of care for them. Since working in a primary health care, prevention and health education are strengthened and greatly emphasized to the patients and interaction is necessary to set goals and prioritize plan of care.

Imogene Kings Goal Attainment Theory in Application to the care of the Child Kings Goal Attainment Theory emphasized the ten concepts as the essential knowledge that nurses must use in concrete nursing situations. In the community setting, some of these concepts are applicable: perception, growth and development, time, communication and interaction. They are useful in promoting and preventing occurrence of health problems which is the prime focus of community health nursing. In care of children in the community setting, promotion of health activities is of priority. Handwashing and cough etiquette lectures are very timely activities today because of the pandemic spread of Influenza A (H1N1). In interacting with children, we utilized colorful instructional materials and terms appropriate for their ages for easier comprehension. Children are encouraged to participate and are recognized when they are able to do the procedures properly. Time is also a basic consideration; lectures were conducted at the early part of the day to assure that there energy levels are still high and that they are prepared mentally. In applying Kings theory, nurses must understand the extent of the childrens understanding about the importance of handwashing and cough etiquette practice. It is also important that nurses must have self-awareness on how he/she perceives the health behavior as well. In dealing with children, the supporting persons are part of the decision making process because children are not yet capable of making decisions concerning their care. If the child and their support system together with the nurse mutually agree to meet a certain goal, then the process outcome will be goal attainment like in our case practice of handwashing and cough etiquette is achieved.

Imogene Kings Goal Attainment Theory in Application to the care of the Adult

Working as a staff nurse in a Primary Health Center, Imogenes theory is realized through the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space with our patients. Most of them are for regular check-up and follow ups which give us opportunity

to plan nursing care and set goals to be achieved by the patients for a certain period of time. Middle-East countries especially gulf area are known to have one of the highest mortality and morbidity rates in Diabetes. Most of them are obese, non-working, and has inactive lifestyle. Diabetic patients are carefully managed in our diabetic clinic. Each of them are given monthly appointments to follow up with the nurse and the doctor to evaluate the care that is planned both by the nurse and the patient to establish a controlled blood sugar, prevent diabetic foot and engage patients in healthy lifestyle. Patients are encouraged and motivated to participate in the care of plan that is most comfortable with them and most importantly within the norms of their society and acceptable to their culture and tradition. They are usually taught to self-inject themselves with insulin or a family member is asked and taught to give insulin to the patient. Patient or a family member is also taught to check and record the blood sugar everyday and to keep a record about the food that the patient has eaten. During their monthly appointment we evaluate all that is taught to the patient and revise everything if it is important and necessary for the health of the patient or we refer them to Hamad General Hospital if it is deemed necessary. Each of them has a registration book where we document everything and where all records are kept. Patients are involved and empowered in a way that they get to have a chance to participate in deciding the plan of care for them. Since working in a primary health care, prevention and health education are strengthened and greatly emphasized to the patients and interaction is necessary to set goals and prioritize plan of care.

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I was able to understand that Imogene Kings conceptual system was used to build a world community of nurses who respect cultural differences and share the mutual goal of health in each nation. Last July 2008, I was given the opportunity to join a Medical Mission held in Phnom Penh, Cambodia for 1 week. It was organized by Youth With A Mission (YWAM), a Christian organization. Together with the health team, we were able to know what the main problem of the community was after the ocular survey. Khmer people living in the slum area were not particular with their hygiene. They dont have proper clothing, took a bath in a muddy river, and they dont brush their teeth. Henceforth, dealing with them was not that easy because of language barrier and culture differences. They dont know how to speak English and part of their culture is to take a bath in the Mekong River from time to time because they believed that the said river can heal their disease. The truth is they dont have enough knowledge and understanding of what could happen to them if they continue it. To solve this matter, we planned to coordinate with their town leader and did some health teachings to the community with the help of an interpreter. We gave them much information about the diseases they could get when they immersed with that kind of water. We also taught them how to brush their teeth properly. Clothes were given and some vitamins as well. We talked with several people and fortunately, they gave us good feedbacks. They were able to understand that the health team had no intention to disrupt their culture but instead, showed them a better way of having healthy bodies through clean-living lifestyle. Through that, I was also able to appreciate one of Imogene Kings assumptions of an individual: that they have the

capacity to think, to know, to make choices, and to select alternative courses of action. It was such a great experience as a nurse!

Imogene Kings Goal Attainment Theory in Application to the care of the Elderly

Caring for the elderly must be done with love and respect. It is a skill that may or may not come naturally to an individual, but either way, members of the family move ahead and do the best they can for their loved one. Three years back, I have a patient who had Alzheimers disease for two years already. As for me, it is one of the difficult patient to encounter since the disease is incurable, degenerative and terminal. She has been in and out of the hospital for several months due to complications of the disease. It has been stressful on the part of the family, looking at the patient day and night suffering from the dreaded disease. One could only imagine how many nights they could not sleep well worrying what will happen the next day. Despite all of what they are facing, they should stay strong. In the midst of what happened those days, I could remember some of the things that I have done for the patient. I can remember the way she greeted me with a smile and simply say hi every time I entered the room. Although sat times shes cranky. I can remember the way she tells stories with enthusiasm. And I can remember the way her family showed their love and affection to her. They hug and kiss her. They try to give the best for her. And I salute them for their patience, love, and generosity. As a nurse and as a person, I never thought I could encounter such patient. I never imagined that it was difficult to approach and manage a patient with Alzheimers. I was depressed then that I could not do anything about the disease. But then again on second thought, why think of the things that I could not even answer?! What I did was, I talked to her family instead. I reached out to her family because I understand what they feel...and I sympathize with them even if I know that this is not good and not a therapeutic way of communicating. I tried my best to attend to the needs of the patient, may it be in physical, emotional, spiritual, and intellectual aspect. Day by day I was beginning to understand the disease per se and eventually the patient. I thought of making a plan and set goals for the patient. My problem then was the patient cannot follow the things that I have to tell her for us to be able to attain our goals. So, I thought of another plan, why not involve the entire family in rendering care to the patient. I told the folks about these and they gladly said yes. Although I could not change the status of the patient in relation to the disease itself, I manage to somehow change a little bit the condition of the patient. Physically, she was able to move some parts of her body to prevent muscle atrophy through the simple exercises and massage that we do to her every morning. Somehow we managed to talk to her even at the peak of her mood swings and let her tell stories of her past experiences as a wife and mother. We managed to let her out of the bed hassle free for quite some time. For some, this might be insignificant changes, but for me and for the family as well, meant a lot already. At times we cannot do all the activities for the day because of her mood swings. We can only react to what

actions she showed to us. If she does not pull her hands and shout at you during the massage of the hands then we continue the massage. If she does not grab the blanket and cover herself during the exercises then we continue the exercise until were done. There are days that we cannot do anything at all. But there are days that we fortunately finish all the activities for the day. These is the way I together with her family, manage the patient.

Imogene King Many people decide to pursue a career in nursing because they want to be instrumental in helping patients get healthy. In order to do that, it's necessary to set health goals with the patient, then take steps to achieve those goals. Imogene King's Theory of Goal Attainment focuses on this process to aid nurses in the nurse-patient relationship, helping their patients meet the goals they set for their health. Biography of Imogene King Imogene King was born on January 30, 1923 in West Point, Iowa. She received her nursing diploma from St. John's Hospital School of Nursing in St. Louis, Missouri, in 1945. In 1948, she earned her Bachelor of Science in Nursing from St. Louis University, and went on to complete her Master's of Science in Nursing, also from St. Louis University in 1957. She also earned her doctoral degree from Teachers College, Columbia University in 1961. She died on December 24, 2007. Career of Imogene King Between 1966 and 1968, King worked as Assistant Chief of the Research Grants Branch of the Division of Nursing in Washington, D.C. under Dr. Jessie Scott. She was the director of the Ohio State University School of Nursing from 1968 until 1972. She was an Associate Professor from 1961 until 1966 and a Professor from 1971 until 1980 at Loyola University in Chicago. After serving as a professor at the University of South Florida's College of Nursing in Tampa, Florida from 1980 until 1990, King retired with the title Professor Emeritus. During her career, King was an active member of the District IV Florida Nurses Association, the American Nurses Association, and Sigma Theta Tau International. She was also a Fellow in the American Academy of Nursing. Imogene King's Contribution to Nursing Theory: Theory of Goal Attainment Imogene King's Theory of Goal Attainment was first introduced in the 1960s. The basic concept of the theory is that the nurse and patient communicate information, set goals together, and then take actions to achieve those goals. It describes an interpersonal relationship that allows a person to grow and develop in order to attain certain life goals. The factors that affect the attainment of goals are roles, stress, space, and time. According to King, the patient is a social being who has three fundamental needs: the need for health information, the need for care that seeks to prevent illness, and the need for care when the

patient is unable to help him or herself. She explains health as involving life experiences of the patient, which includes adjusting to stressors in the internal and external environment by using resources available. The environment is the background for human interaction. It involves the internal environment, which transforms energy to enable people to adjust to external environmental changes, and it involves the external environment, which is formal and informal organizations. A nurse is considered part of the patient's environment. The three interacting systems in her Theory of Goal Attainment are the personal system, the interpersonal system, and the social system. Each system is given different concepts. The concepts for the personal system are: perception, self, growth and development, body image, space, and time. The concepts for the interpersonal system are: interaction, communication, transaction, role, and stress. The concepts for the social system are: organization, authority, power, status, and decision making. King's Theory of Goal Attainment defines nursing as "process of action, reaction and interaction by which nurse and patient share information about their perception in nursing situation." According to King, nursing's focus is on the care of the patient, and its goal is the health care of patients and groups of patients. According to King, the goal of the nurse is to help patients maintain health so they can function in their individual roles. The nurse's function is to interpret information in the nursing process, to plan, implement, and evaluate nursing care. In the nurse-patient relationship, the nurse first uses his or her knowledge base to assess the patient and make a diagnosis. After the diagnosis, the nurse creates a plan for interventions to solve problems that were identified in the assessment and diagnosis. Once a care plan is created, actions are implemented to achieve the patient's health goals. Finally, the nurse evaluates the patient to determine whether or not the goals were achieved. In the healthcare field, the ultimate goal in the nurse-patient relationship is to help the patient achieve his or her goals for getting healthy. By using the nursing process described in Imogene King's Theory of Goal Attainment, a nurse can be more effective in working with a patient to achieve those goals, and can truly help patients.