Imogene King developed a conceptual model for nursing in the mid 1960’s with the idea that human beings are open systems interacting with the environment (King, 1981). King’s work is considered a conceptual model because it comprises both a conceptual framework and a theory (Fawcett, 2000). King’s Conceptual Framework and Theory of Goal Attainment are being used as a model as it is applied in the community nursing setting.
WHAT’S IN A NAME?
IMOGENE KING was born in 1923, the youngest of three children. She received her basic nursing education from St. John’s Hospital School of Nursing in St. Louis Missouri, graduating in 1946. Her BS in nursing education (1948) and MS in Nursing (1957) are from St. Louis University and her EdD (1961) is from Teacher’s College, Columbia University, New York. She has done postdoctoral study in research design, statistics, and computers (king,1986b). King has had experience in nursing as an administrator, an educator and a practitioner. Her area of clinical practice is adult medical-surgical nursing. She has been a faculty member at St. John’s Hospital School of Nursing, St. Louis; Loyola University, Chicago; and the University of South Florida. She served as director of the School of Nursing at the Ohio State University, Columbus. She was an Assistant Chief of the Research Grants Branch, Division of Nursing, Department of Health, Education and Welfare in the mid-1960s and on the Defense Advisory Committee on Women in the Services for the Department of Defensein the early 1070’s. She is retired from the University of South Florida and continues to consult and work on the further application of her theory (George, J. Nursing Theories The Base for Professional Nursing Practice 4th edition 1999).
King’s conceptual framework includes three interacting systems with each system having its own distinct group of concepts and characteristics. These systems include personal systems, interpersonal systems, and social systems. King’s basic assumption maintained that nursing is a process that involves caring for human beings with health being the ultimate goal (Torres, 1986). The three systems that constitute King’s conceptual framework provided the basis for the development of her Theory of Goal Attainment.
1. The personal system that King speaks of refers to the individual. The concepts within the personal system and fundamental in understanding human beings are perception, self, body image, growth and development, time, and space (King, 1981).
2. Interpersonal systems involve individuals interacting with one another. The concepts associated with interpersonal systems are interaction, transaction, communication, role and stress.
3. Social systems are groups of people within a community or society that share common goals, interests, and values. Social systems provide a framework for social interaction and relationships, and establish rules of behavior and courses of action (King, 1971).
GOAL ATTAINMENT THEORY AS APPLIED TO COMMUNITY HEALTH NURSING
Using King’s Theory of Goal Attainment in the community can serve as a guide for formulating community nursing diagnoses process.
People in the community are independent, hard-working, and self-sufficient individuals who consider themselves healthy if they are able to go to work each day and perform their usual activities of daily living (Weinart & Long, 1987). Because of the strong work ethic in communities, health care needs often come second to work needs. People in the community are more likely to comply with health care regimens that do not interfere with their daily routines, or create inconveniences for them. For these reasons, nurses dealing with community people must be perceptive and creative enough to devise a plan in implementing community programs.
Ideally, prior to immersion to the community; the nurse should follow the standard steps/phases: the Pre-orientation, Orientation, Working and Termination phase. These will really help her/him to take root and become one of the community people. Once the community has recognized the presence, efforts and best intentions of the nurse and when the nurse herself/himself has established a good reputation for being a good model and member of the community, only then s/he can be able to implement health-promoting behaviors, promotion, education and utilization of health programs and the like.
If the students can’t do the fundamentals, How can they use advanced knowledge?” – Imogene King
Interaction - King defines it as “ a process of perception and communication between person and environment and between person and person, represented by verbal and non-verbal and non-verbal behaviors that are goal directed”.
Perception - “each person’s representation of reality”. According to King, this concept includes the import and transformation of energy, and processing, storing, and exporting information. Communication-defined as a process whereby information is given from one person to another either directly or indirectly. The exchange of verbal and non verbal signs and symbols between the nurse and client or client and the environment, is communication.
Transaction - are defined as purposeful interactions that lead to goal attainment.
Role -was defined as a set of behaviors expected of persons occupying a position in a social system If expectations of a role differ, then role conflict and confusion exists. This may lead to decreased effectiveness of the nursing care provided.
Stress - is a dynamic state whereby a human being interacts with the environment. An increase in the stress of individuals interacting can narrow the perceptual field and decrease rationality. An increase in stress may also affect nursing care. different knowledge, needs, goals, past experiences and perceptions, which influence the interaction”. Growth and Development-King defined these terms as “continuous changes in individuals at the cellular, molecular and behavioral level of activities… conducive to helping individuals move toward maturity.”
Time -is defined as a sequence of events moving onward to the future…Time is a duration between one event and another as uniquely experienced by each, human being”
Space - “is defined as existing in all directions and is the same everywhere. Space is the immediate environment in which nurse and client interact.”
King’s personal philosophy about human beings and life influence her assumptions. Her conceptual framework and the 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 a social roles.”
Nursing - Nursing is an observable behavior found in the healthcare system in society.” The goal of nursing is to help individuals maintain their health so they can function in their roles. Nursing is viewed as an interpersonal process of action, reaction, interaction and transaction. Perception of nurse and client also influence the interaction process.
Person - Specific assumption relating to person follow:
Individuals are social beings. Individuals are sentient beings Individuals are rational beings Individuals are perceiving beings Individuals are controlling beings Individuals are purposeful beings Individuals are action-oriented beings Individuals are time-oriented beings
King wrote Individuals have a right to knowledge about themselves…a right to participate in decisions that influence their life, their health and community service….a right to accept or reject health care.
Health - Health implies continuous adaptation to stress in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living. Health is the function of nurse, patient, physician, family and other interactions.
Environment - King states An understanding of the ways that human beings interact with their environment to maintain health is essential for nurses. Open systems imply interactions occur between the system and its environmet, inferring that the environment is constantly changing. Adjustments to life and health are influenced by an individual’s interactions with the environment. Each human being perceives the world as a total person in making transactions with individuals and things in the environment
APPLICATION OF KING'S THEORY
Gina is a 19 year old nursing student in Davao. She is known in school as an academic achiever and top student, and is often seen reading books. She has a sensitive personality, often having meaningless grudges, low self-esteem on her appearance, and feelings of inadequacy over the shallowest things. She cannot communicate her thoughts well to her classmates, friends and family, which leaves them guessing on her real feelings. Some got tired of understanding her and simply did not care anymore.
One day, the client has been diagnosed with gastric ulcer (damage to the stomach wall) after coming to the emergency room of a public hospital. She showed signs of vomiting and severe stomach pain measuring 8 out 0f 10 on the pain scale, appearing thin, pale and weak. She was weighed, and it was discovered that her weight is not appropriate for her age and height. Before arriving at the hospital, the client was explaining to the ER nurse that she has a dietary pattern of eating twice a day with little breakfast, sometimes even without lunch, for she spends a lot of time at the library. Her twenty four-hour dietary intake is made up of meats, rice, vegetables and drinking sodas every time she feels thirsty. Prior to admission, she has not eaten for 8 hours. She was taken to the medical-surgical ward for observation, while different diagnostic tests was ordered by the physician and carried by the nurses. A staff nurse was tasked to interview Gina, complete her Patient History and give her nursing care. The patient at first did not want anything to do with the nurse, saying” ayos lang po talaga ako ate” and “wala naman pong problema talaga.”
The nurse would assessed the client’s present condition, including the physical signs, symptoms and feelings about self and people. Her thin body, meal skipping would indicate some degree of malnutrition, and her timid responses would point to inadequate social skills. Taking careful note of the abnormal eating habits of the patient, the nurse would create a plan of care that deals with the need for information, illness prevention in the future, and most importantly, giving nursing care for her present condition. A careful evaluation of her personality and behavior would also be done to enable healthy responses to stress and conflict, most especially on self-expression and socialization behaviors.
1.Assess physical condition, health beliefs and perceived level of wellness of the patient using therapeutic communication and physical assessment techniques.
2.Using King’s Goal Attainment Theory, give Gina some health teachings, particularly exploring her imbalance about internal stressors, and which would be her inadequate stress coping and low self esteem. Teach client stress management techniques and refer to a Psychologist, Spiritual adviser or support system like family and friends for counseling.
3.Teach the client to change her diet according to the Recommended Dietary Allowance (RDA), age and lifestyle. Show some visual aids and illustrations showing some recommended food groups. Collaborate and refer her to a registered nutritionist-dietician (RND) for additional counseling.
4.Take care of the client’s current nursing problem of discomfort through non-pharmacologic (without drugs) pain lessening techniques and giving pain medications as ordered by the physician.
5.Continue nurse interaction and therapeutic communication with the client, and convince Gina to fulfill a “contract” that both the nurse and the patient would agree to participate in activities that promote health as a major goal.
Patient x is a 2 year old child with central nervous system infection, confined in a government hospital, his father is a tricycle driver and his mother has no job, the couple is looking for ways to buy the antibiotics which are prescribed. I was asked of the background of the illness of their child, they said that they did not understand what the doctor told them. I willingly explained to them the illness as far as my knowledge is concerned. They thanked me for being accommodating. After the conversation they realized how important the medication therapy is, however their means are limited. I showed them to the department of social works in the hospital to be able to ask some help. With the communication that transpired the parents had a clearer view of the situation of their child. Therefore, given this situation the goal of participating in the management of their child's illness was achieved.
After careful analysis of King’s Conceptual Framework and Theory of Goal Attainment, it is evident that this model can be implemented in an emergency room setting. The concepts associated with the personal system can be integrated into the assessment phase of the nursing process. Initial assessment of a patient is of utmost importance in the emergency room, especially with regard to trauma patients. However, after completion of the primary survey (airway, breathing, and circulation), nurses should take into account the patient’s feelings in regard to perception, self, body image, growth and development, time, and space. Disturbances in perceptions of self and body image often occur in trauma patients who have sustained significant bodily injury.
A classic example of this in an emergency room setting involved a young college student who had a traumatic amputationof an arm due to a motor vehicle accident. Once this patient was stable from a hemodynamic standpoint, the nurse’s attention was refocused on assisting the patient in coping with the feelings of loss, separation, and anger that he was experiencing. Attempting to restore this patient’s self-esteem, in light of his traumatic loss, was a mutually established goal between the nurse and the client. In this particular example, it was also important for the nurse to realize that the patient’s perceptual field was narrowed because of the pain and emotion that he was experiencing.
A busy emergency department often creates an intimidating environment for patients and they may feel threatened, or feel that they have no control over decisions that affect their care.
A clinical example of this occurred recently when a middle-aged woman who was experiencing acute pulmonary edema was brought to the emergency department by her husband. Because of the severity of her condition, the emergency room nurses caring for this patient immediately began taking actions to stabilize her condition, such as securing an IV line, drawing blood for labs, applying oxygen, and inserting a foley catheter. At the same time, the patient was asking, “what are you doing to me?” When the patient’s condition did not significantly improve, the physician explained to the patient and the husband that she needed to be placed on a ventilator to assist her breathing. The client was adamant that she did not want to take drastic measures, but the husband indicated that he wanted whatever was necessary to improve his wife’s condition. This is an excellent example of a client losing the sense of self-hood. In regard to the concept of self, King (1981) stated “If nurses and other professionals interact with patients or clients as human beings, and let the individuals be themselves, even if they do not match the stereotype of the ‘good patient’, nurses and patients would help each other grow in self-awareness and in understanding of human behavior, especially in stressful life experiences”.
The primary complaint of emergency room patients is the length of waiting time. Waiting two hours for test results may seem like an eternity for the patient, but for the nurse, time passes swiftly because s/he is usually busy caring for other patients, or performing other duties. King (1981) emphasized that waiting makes time seem even longer. One intervention that has proven successful in this situation has been the installation of televisions and telephones in patient rooms in the emergency department. These devices seem to help the patients pass the time and reduce some of the frustrations associated with long waiting times.
Of all the concepts mentioned in regard to interpersonal systems, communication requires the most attention in the emergency department. Good communication skills are imperative in the emergency room setting. In an environment that requires one to be reactive and responsive, clients often perceive nurses as being too busy or too hurried. King (1981) encouraged nurses to be aware of how they present themselves to their clients because the manner in which nurses enter a client’s room sets the tone for the entire encounter. Poor communication skills lead to poor transactions and interactions between the nurse and the client. Poor communication skills also affect goal setting and goal attainment. This is especially true in the emergency department as evidenced by patients returning for follow-up visits who have not followed their discharge instructions, and hence, their health has suffered.
A clinical example of this is a young adult male with diabetes who was treated recently in an emergency department for a wound to the lower leg. The patient returned for a follow-up visit with the wound open to air and infected. An in-depth assessment revealed that the patient did not understand the dressing needed changing daily and that he need to keep the extremity elevated. This lack of communication between the nurse and the client resulted in goals not being attained.
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