King's Theory of Goal Attainment in Nursing Practice

Origins of Modern Nursing Theory

Modern nursing practice officially began with Florence Nightingale, who described nursing knowledge and medical knowledge as distinct disciplines. Theory-based nursing practice is a phenomenon that has been researched extensively. Wold (1981) noted that "as a result of the broad client systems to be served and the duality of the school nurse's expected allegiances, school nursing today is a complex practice specialty" (p. 30). In recent times, it has become necessary to ground nursing and clinical practice in a theory or conceptual framework.

Today's nursing theorists stand on the shoulders of giants in the field, and it is not surprising that new evidence-based approaches continue to be developed and refined. The origins of modern nursing theory can be conceptualized as existing along a continuum beginning with Nightingale and continuing to the present. Theorists such as Dorothy Johnson and Dorothea Orem dominated the early stages of nursing theory development, while others such as Virginia Henderson and Imogene King built on their seminal work during the mid-twentieth century.

An analysis of King's Theory of Goal Attainment following the guidance provided by Fawcett stipulates that "theory analysis involves a nonjudgmental, detailed examination of the theory," including its (a) context, (b) content, and (c) scope. Each of these dimensions is addressed in the sections below.

King's Theory of Goal Attainment: Context and Content

The current recognition of the need to base nursing practice on theory is reflected in Standard I of the American Nurses' Association's Standards of School Nursing Practice, which states: "The school nurse applies appropriate theory as a basis for decision making in nursing practice" (American Nurses Association, 1983, p. 3). Consequently, nursing has been established as a profession requiring a divergent knowledge base. During the early twentieth century, "nursing practice was based on rules, principles, and traditions that were passed along through limited apprenticeship forms of education" (Chang, Chenoweth, & Hancock, 2003, p. 36). Most of those principles were adopted from disciplines such as physics and biology, and while they were assumed valid for nursing, they were not assessed in relation to nursing practice.

By the mid-twentieth century, nursing practice shifted from a fact-oriented viewpoint toward effective, evidence-informed practice. Nursing programs began preparing nurses in higher education institutions, and early nursing theories emerged alongside the development of nursing skills and scientific methodology. The usual role of the nurse also changed substantially during the latter decades of the twentieth century. Previously, nurses were not expected to make independent and complex decisions. Today, nurses are independent professionals who operate multifaceted equipment, calculate drug dosages, and select appropriate treatment options for their patients (LeTourneau, 2004).

Nurses have gained credibility with both patients and the broader healthcare team, who value their knowledge, skills, and contribution to holistic care. Nursing observations and assessments guide care plans and resulting interventions. Both independent and interdependent interventions require nursing judgment and represent essential nursing functions (Logan, 1990).

A number of philosophical and grand nursing theories have been developed over the years to facilitate the delivery of high-quality health care, including King's Theory of Goal Attainment. Representative examples are set forth in Table 1 below.

Table 1: Representative Nursing Theories over Time (Adapted from Joel & Kelly, 2002, pp. 180, 182)

The table includes the following theorists and frameworks: Florence Nightingale's adaptation/environmental theory (1859), which held that disease is a reparative process and that imbalance between patients and their physical environment frustrates energy conservation; Dorothy Johnson's behavioral systems theory (1959), organized around seven behavioral subsystems analyzed in terms of structure and function; Dorothea Orem's self-care model (1959), constituted from theories of self-care, self-care deficit, and nursing systems; Virginia Henderson's developmental model (1961), which viewed the patient as a person requiring help toward independence; Ida Jean Orlando's interpersonal theory (1961), which distinguished automatic from deliberate action; and Imogene King's open systems model (1964), which assumed the dynamic nature of life requires continuous adjustment to stressors and that adjustment involves three interacting open systems — personal, interpersonal, and social.

King's Theory of Goal Attainment, which describes the nurse-client relationship, stems from this grand theoretical tradition. Its tenets have taken their place among the influential grand and philosophical nursing models that emerged during the mid-twentieth century.

King (1992) presented her goal attainment theory as applicable to nursing care and patient satisfaction. It provides a theoretical framework for patient satisfaction with nursing care specifically because its central focus is the interrelationship of patient and nurse. King derived her Theory of Goal Attainment (TGA) from the General Systems Framework (GSF). From King's perspective, a system is defined as "a series of functional components connected by communication links exhibiting purposeful, goal-directed behavior" (1997, p. 22). King's philosophical approach drew from systems thinking and holism developed within the behavioral sciences.

King's GSF consists of three dynamic interacting systems: personal (individuals), interpersonal (groups), and social (society). Individuals involved in a dyad are referred to as personal systems. Key concepts relevant to understanding human behavior and individuals include self, body image, growth and development, time, and space. Interpersonal systems encompass dyads and groups and are understood through concepts such as role, interaction, communication, transaction, and stress. Social systems reflect the dynamics of society, and nurses operate within them through their organizations, decision-making authority, professional status, and roles.

King (1981) defined nursing as "a process of interactions between nurse and client whereby each perceives the other and the situation; through communication, they set goals and explore and agree on the means to achieve the goals. Actions are taken as necessary by both the patient and the nurse to achieve their mutual goals. Transactions have occurred when goals are attained" (King, 1992, p. 23). Thus, goal attainment as presented by King is described as a process of reaction–interaction–transaction in which perceptions, interactions, and communication between nurse and patient are the major factors. The TGA affirms that patients hold different viewpoints and opinions compared to nurses, even as both continuously interact. King emphasized that nursing professionals should access data about patients' perceptions in order to make provider and patient goals harmonious (King, 1992).

Nurse-Patient Interaction and Patient Satisfaction

Research has consistently demonstrated that nurse-patient interaction and communication play the most influential role in patient satisfaction. King's Model of Goal Attainment provides the theoretical framework for understanding how this occurs. Eriksen (1995) concurs with King's TGA in defining patient satisfaction with nursing care: transactions between nurse and patient will result in the achievement of the goal of patient satisfaction, and this outcome can only be obtained through communication, interaction, and mutual perception between nurse and patient.

Several authors have supported and elaborated on King's concept of nurse-patient communication. Webb and Hope (1995) described it as "purposeful communication and information sharing between the patient and the nurse." In their structured interview study with 103 inpatients, they reported that patients identified nurses' listening to their concerns, teaching them about their conditions, and providing pain relief as the most important nursing activities.

Earlier studies included patient expectations as an independent variable but often lacked rigorous scientific methodology (Linder-Pelz, 1982). Some studies (Korsch, Gozzi, & Francis, 1968; Larsen & Rootman, 1976) gathered expectation and satisfaction data during the same time period, limiting their reliability. Swan, Sawyer, Van Matre, and McGee (1985) examined a path model exploring the relationship between patients' expectations and their general satisfaction, finding a strong link between the fulfillment of expectations and overall satisfaction — though the validity of this study is limited because patients were assessed after discharge via mailed surveys.

Patient satisfaction with nursing care is a complex phenomenon consistently associated with the quality of nursing care. Research indicates that satisfaction is influenced by patients' expectations, with an inverse relationship — lower expectations are associated with higher satisfaction (Cleary, Horsfall, & Hunt, 2003; Han, Connolly, & Canham, 2003). However, multiple studies indicate that patients will be satisfied when actual performance meets or exceeds their expectations (Abramowitz, 1987; Cleary et al., 2003; Greeneich, 1993; Linder-Pelz, 1982; Nguyen Thi, Briancon, Empereur, & Guillemin, 2002).

The majority of research studies have concluded that the most important factor in overall patient satisfaction is satisfaction with nursing care specifically. Wolf (1998) found a "highly statistically significant relationship between patient reports of nurse caring and satisfaction with nursing care" (pp. 103–104). Schmidt (2003, p. 393) elaborated on this significance: "As nursing represents a constant presence in the experience of hospitalized patients, it seems logical that satisfaction with nursing care has a primary influence on patients' overall satisfaction with their experience."

Carey and Posavac (1982) conducted a survey with 176 discharged patients and reported that satisfaction with nursing care was the most important factor in how patients rated the hospital overall. Using a standardized 54-item mail survey, they found that 90% of patients who rated the hospital as excellent also described nursing services as excellent, compared with only 32% among less-satisfied patients. Participants identified technical competence, a supportive attitude, responsiveness, and information-giving as the most important nursing abilities.

Doering (1983) similarly investigated factors influencing patient satisfaction with care using an 11-item Likert scale survey. Using Cramer's V coefficient to describe associations, the study reported that patients' overall satisfaction was more closely linked to their satisfaction with nursing care than to any other service received during their hospital stay.

Frey (1995) reported that a large urban medical center in Florida implemented King's TGA and surveyed surgical patients before and after the implementation using Hinshaw and Atwood's Patient Satisfaction Inventory (1982). Frey reported that the control group showed lower satisfaction compared to the experimental group (N = 180, M = 3.6, p < .02), concluding that the implementation of theory-based nursing practice helps improve patient satisfaction.

Conclusion

The current paper was a discussion of King's Goal Attainment Theory and its scope as well as its real application. The author discussed the origin of King's Goal Attainment Theory, its application to patient care, and different aspects of interpersonal communication. A review of the literature shows that theory-based nursing has become increasingly important, and that nursing has evolved into a profession with a distinct knowledge base. It is also evident that nursing care approaches have shifted from fact-based nursing toward a focus on patient satisfaction with nursing care.

The research showed that King presented her Theory of Goal Attainment model (TGA) in 1981, with origins in the general systems framework, holism, and the social and behavioral sciences. The theory is well-suited for implementation in patient care contexts because it focuses on patient-nurse interactions, viewing them as "a series of functional components connected by communication links that exhibit purposeful, goal-directed behavior" (King, 1997).

In summary, the Theory of Goal Attainment maintains that "individuals comprise one type of system in the environment called personal systems. Individuals interact to form dyads, triads, and small and large groups, which comprise another type of system called interpersonal systems (nurse/patient). Groups with special interests and needs form organizations, which make up communities and societies and are called social systems" (King, 1981). The theory further suggests that if nurses are able to better understand patients' expectations, they can improve the mutual relationship — and that this improvement is further enhanced when nurses can openly discuss those expectations with patients. As a theoretical framework, the TGA continues to offer a valuable and adaptable foundation for nursing practice, education, and research.

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