The thrust of Imogene King's theory of goal attainment is a loosely-coupled partnership between the nurse and the patient that enables communication about the patient's condition, their health goals, and a plan of action to achieve the patient's goals. The conceptual framework is based on systems theory -- and King employs the three classic systems in her representation of her theory: (1) the personal system, (2) the interpersonal, and (3) the social system. As the conceptual framework takes shape for the personal system of the individuals in the schema (Yonge, 2007), several constructs emerge: Body image, self, growth & development, perception, space, and time. As the conceptual framework moves to the interpersonal systems, the constructs take on a more integrated form: communication, interaction, transaction, time, and space. In the last component of the conceptual framework, the constructs of authority, status, power, decision-making, and organization become important.
Elements of the theory. Undergirding King's theory is the principal that a patient is able to develop and grow, moving toward attainment of life goals -- it is not illness or disease that erodes this ability to be goal-focused so much as it is the constraints of the roles of the individuals, and issues of stress, time, and space (Stizman & Eichelberger, 2011). The internal and external environments of the patient and nursing context are the backdrop for the interactions that take place during the time of care or treatment (Stizman & Eichelberger, 2011). The patient and the nurse must make adjustments in response to the stressors in the internal and the external environments, as they encounter them (Stizman & Eichelberger, 2011; Zust, et al., 2010). The external environment entails the informal and formal social arrangements of the lives of the patient and the nurse (Stizman & Eichelberger, 2011). The internal environment is not directly observable, but it is the context in which energy is transformed, which facilitates adjustment to and abrogation of the external environment (Stizman & Eichelberger, 2011). The interactions of these systems form the basis of the nursing relationship (Stizman & Eichelberger, 2011). Nursing is qualitatively defined in the theory as the actions, reactions, and interactions between the nurse and the patient as they share information about their perceptions in the nursing-patient situation (Stizman & Eichelberger, 2011). It should be apparent, according to King, that the focus of the nurse must be squarely on patient care, and the goal of nursing and health care is quality caretaking of the patients (Stizman & Eichelberger, 2011). The extension of this orientation toward nursing is the effort of the nurse to help patients be and stay healthy so that they can function in their life roles (Stizman & Eichelberger, 2011). For the nurses' part, the objectives are to provide and interpret information about the nursing process, to plan for the provision of care, to implement care of the patient in a best practices format, and to evaluate the nursing care provided in an effort to carry out the first two objectives (Stizman & Eichelberger, 2011).
Philosophical underpinnings. King's theory of goal attainment is fundamentally a humanistic theory in which the patient retains the rights and strengths and liabilities of any social being, regardless of the physical, mental, and emotional states manifested (Zust, et al., 2010). Without explicitly articulating the following principals, King makes it nonetheless clear that certain attributes of nursing care will color the patient-nurse relationships (Yonge, 2007). These components reflect the highest order of relationships, including an overarching reverence for living things and for life, a determination to act on professionally and personally held beliefs, and a fundamental respect of the autonomy, dignity, individuality, and worth of each patient. These three components are the ethical and philosophical building blocks of nursing theory (Tomey & Alligood, 2002). Philosophy is held in the mind and heart, but it is conditioned by purpose, and manifested in practice (Plager & Conger, 2008). Purpose is connected to a nurse's theoretical foundation as a nexus between philosophy and practice. Practice is all of the observable nursing actions directed toward meeting patients' needs and working for the overall good of the patients under her care (Tomey & Alligood, 2002).
Transactional need states. Three primary and fundamental needs are accorded to the patient in King's theory. They are (1) the need for information about their health or condition, (2) the need for healthcare that is focused on preventing or treating disease, and (3) the need for a deep level of care should the patient be unable to provide self-care. The paramount goal in the nurse-patient relationship is to foster attainment of the patient's goals for becoming healthy (Leipert, 2007). This is a multistep / multistage process that is like a dance shared by the patient and the nurse (Plager & Conger, 2008). As the nurse is in a position to interpret information and use knowledge to assess and diagnose the patient, these early actions are the precursors for subsequent actions between the patient and the nurse (Plager & Conger, 2008). Once a diagnosis has been accomplished, the nurse moves to the next stage, which is generating a plan of actions and interventions that are designed to help solve the problems that are associated with the diagnosis and any subsequent assessments (Plager & Conger, 2008). The next step is that an action plan will be established to aid the patient in efforts to achieve healthy goals. Finally, an evaluation of the effectiveness of the intervention or treatment plan is conducted in order to determine if the patients' goals have been met.
Theory into practice. In complex nursing situations or roles that occur in contexts characterized by more than one system -- such as family nurse practitioners -- King's theory provides a platform for keeping the purpose of nursing top of mind while simultaneously offering flexible guidelines for practice (Yonge, 2007). Two distinct strengths of King's theory is that the theoretical underpinnings can be adapted to contexts that may be in a state of flux, or to reframed as a nurse moves from one type of context or environment to another (Jukkala, et al., 2010).
An analysis of the attributes of a theory must include an examination of the following: Identifiable paradigm, logical structure, generalizability, hypotheses, capacity to extend the literature through research, praxis guidance, cross-theoretical consistency and validity (Jukkala, et al., 2010). Consideration of these attributes of theories with regard to King's theory follows:
Identifiable paradigm. King's goal attainment theory is manifested against a background of transaction analysis, borrowing from psychology and sociology, as well as medicine. The theory assumes that the patient is an independent, goal-directed agent capable of interacting with environmental and interpersonal aspects of life.
Logical structure. The goal attainment theory is based in systems thinking which employs a very logical structure of interlocking components, each independent as an entity, but unavoidably impacted by other systems that exist within the context. For example, it is not possible to separate the actions of the nurse from the clinic or hospital environment. Two systems -- one individual and one organizational -- coexist and are mutually influential.
Generalizability. For a theory to be useful, it must exhibit the capacity to be generalized to other similar situations. The goal attainment theory, then, must apply to clinic-based and home-based care, to patient care in urban hospitals and to patient care in rural clinics. The research shows that this attribute applies to King's goal attainment theory (Leipert, 2007; Williams, 2001).
Hypotheses. Certainly King's goal attainment theory can be subject to the same empirical rigor as other social sciences, such as psychotherapy and social work. Hypotheses related to the goal attainment theory are likely to be based on data collected about the assessment and diagnoses of patients, the communication and planning processes of patient care, and organizational issues such as role clarification and, naturally, goal attainment.
Extend the literature. The capacity of the goal attainment theory to contribute to and extend the research is limited only by the creativity of nurses to conduct hypothesis testing or carry out ethnographic research.
Praxis guidance. Many approaches to research are available to practicing nurses, and one of the most effective -- given that qualitative and quasi-experimental approaches are likely to be dominant in patient care research -- is action research. Embedding the research in the nursing practice can result in nuanced change and a deeper understanding of how to improve patient care when the unit of analysis is the transaction between patient and nurse.
Cross-theoretical consistency and validity. Given that goal attainment theory is multidisciplinary, King's theory demonstrates consonance with other social science theories (Jukkala, et al., 2010). The same threats to validity that occupy the research space of these shared theoretical constructs and associated research apply to goal attainment theory -- the same level of scientific rigor is required, whether quantitative or qualitative approaches are employed.
The art of nursing is an overlay of the philosophy, purpose, and practice of nursing. It consists of the understanding that the nurse…