Interacting Systems Theory and Theory of Goal Attainment Imogene King Interacting Systems Theory and Theory of Goal Attainment Erin Swartz, Megan Childers and Elizabeth Mitchell

Introduction Personal, Interpersonal, Social Relationships and Goal Attainment The patient’s perspective Many people pursue the profession of nursing to help people reach the ultimate goal of health. Imogene King developed a nursing theory that focuses on the integration of the personal, interpersonal, and social relationships a person has in relation to goal attainment (Chitty & Black, 2011, p.312). The focus of King’s theory is to provide insight on a person’s perspective of his/her interactions with other people. The nursing focus of King’s theory is the care of the human being and goal attainment through effective communication (Chitty & Black, 2011, p. 312). After a nurse-patient relationship has been established, goals and interventions can be planned and acted upon mutually in hopes of achieving the best patient outcomes. Chitty, K. K., & Black, B. P. (2011). Professional nursing concepts and challenges (6th ed.). Maryland Heights, MO: Saunders Elsevier.

Background 1945 Nursing Education 1948 BSN 1957 MSN 1961 Doctor of Education 1981 Published “A theory for nursing: Systems, concepts, process.” King gained her basic nursing education from St. John’s Hospital School of Nursing in St. Louis, Missouri in 1945, her BSN in 1948, and completed an MSN from St. Louis University in 1957 (Chitty & Black, 2011, p.311). She received her doctor of education from Columbia University in 1961 (Chitty & Black, 2011, p.311). King spent most of her focus in academia and formulated methods to help nurses form a dynamic and trusting nurse-patient relationship. King also had nursing experience as an administrator, an educator, and a practitioner in medical-surgical nursing. In 1981 she published her final form of “A theory for nursing: Systems, concepts, process” (Chitty & Black, 2011, p.312). Chitty, K. K., & Black, B. P. (2011). Professional nursing concepts and challenges (6th ed.). Maryland Heights, MO: Saunders Elsevier. King, I.M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley.

Theory The nurse-patient relationship Setting goals King’s goal of nursing The premise of King’s theory is the importance of the nurse-patient relationship, working together and strategizing transactions so goals can be set and achieved (King, 1981). Each person has an individual purpose and unique perspective for goal attainment. Interventions are made and implemented after the goals are mutually set and agreed upon to promote health for the patient. King’s goal of nursing “is to help individuals maintain their health so they can function in their roles” (King, 1981). King, I.M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley.

Values and Knowledge Value of working together Nurse contribution Patient contribution Definition of nursing According to King, nursing's focus is on the care of the patient, and its goal is the health care of the patient (Williams, 2001, p.25). King emphasizes that both the nurse and the patient bring knowledge and information to the relationship and that they work together to achieve goals (Chitty & Black, 2011, p.312).  Nurses contribute to the relationship by having a special knowledge and a learned skill base. Clinical reasoning and judgment provide insight on effective interventions needed for goal attainment. Interventions should reflect promoting, maintaining, and restoring health for the patient (Seiloff, 1991). The patient has an awareness of self. The patient may also have perceptions and concerns of the health problems. The patient has a voice and is the most important member of the health care team. King (1981) defines nursing as the "process of action, reaction and interaction by which nurse and patient share information about their perception in nursing situation." King, I.M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley. Seiloff, C.L. (1991). Imogene King: A conceptual framework for nursing. Newbury Park, CA: Sage. Williams, L.A. (2001). Imogene King’s interacting systems theory: Application in emergency and rural nursing. Online Journal of Rural Nursing and Health Care, 2(1). Retrieved from: http://www.rno.org/journal/index.php/online-journal/article/viewFile/93/89

Nursing Knowledge Collecting data Evaluating the patient including personal, interpersonal and social systems Encouraging patient participation Importance of communication The nurse will need to collect data to establish the patient’s need and limitations for goal attainment. The patient’s view of self, perception of current health status, communication strategies, preferred learning style, and social influences need to be evaluated to identify the congruity of the personal, interpersonal, and social systems (Seiloff, 1991). A fundamental role of the nurse is to encourage mutual participation in interaction with the patient regarding care. The nurse should focus on the needs and welfare of the patient while verifying the patient’s perceptions on the planned interventions. Open and honest communication will enable them to achieve the goals together. Seiloff, C.L. (1991). Imogene King: A conceptual framework for nursing. Newbury Park, CA: Sage.

Influences Nursing in the1970-1980’s Nurse Practice Act General Systems Theory Kaufman, Orlando and Peplau King’s theory was influenced by factors that were significant during the decade of 1970-1980. The decade presented with knowledge expansion, social changes, educational standard changes, scope of nursing practice, and dimensions evolving in the healthcare system. Nursing was striving for status as a respected science and a legitimate profession (Williams, 2001, p.27). King strived to understand the nurse practice act and in 1972 read her professor’s course work that expanded on literature systems analysis and General Systems Theory by Von Bertalanffy. The General Systems Theory served as the foundation for the development of King’s conceptual framework of the person, interpersonal, and social relationships (Chitty & Black, 2011, p.312). King researched the works of Kaufman, Orlando, and Peplau which provided insight on the concepts of personal relationships (Seiloff, 1991). Furthermore, King studied with colleague Peplau which revealed the relation of their works in connection to patient outcomes. Goal attainment was dependent on patient satisfaction and achievement of patient outcomes (Williams, 2001, p.27). King developed her theory to understand the many functions and roles of nurses and how nurses continuously learn to provide quality and evidenced-based patient care (Seiloff, 1991). Chitty, K. K., & Black, B. P. (2011). Professional nursing concepts and challenges (6th ed.). Maryland Heights, MO: Saunders Elsevier. Seiloff, C.L. (1991). Imogene King: A conceptual framework for nursing. Newbury Park, CA: Sage. Williams, L.A. (2001). Imogene King’s interacting systems theory: Application in emergency and rural nursing. Online Journal of Rural Nursing and Health Care, 2(1). Retrieved from: http://www.rno.org/journal/index.php/online-journal/article/viewFile/93/89

Four Global Concepts Personal System Interpersonal System Human Beings, Environment, Health and Nursing Personal System Interpersonal System Social System Definition of Nursing King’s theory has three interacting systems: personal, interpersonal, and social systems. Concepts are given for each system. Concepts for the Personal System are perception, self, growth and development, body image, space, and time. A human being is defined as a social being that is rational and sentient (King, 1981). A person has the ability to perceive, think, feel, choose, set goals, and make decisions related to health care (Williams, 2001, p.26). Concepts for the Interpersonal System include interaction, communication, transaction, role, and stress. The definition of health is the ability of a human being to react and adjust to life experiences (Williams, 2001, p.26). A human being makes continuous adjustments to internal and external stressors by optimizing resources and developing coping mechanisms to achieve functional status. Concepts of the Social System include organization, authority, power, status, and decision making. Environment is the background for human interactions (Williams, 2001, pg. 26). There are two types of environment, internal and external. The internal environment refers to the human’s perception and ability to adjust to the external environment. The external environment is any organization, such as the hospital. The nurse is a vital part of the patient’s environment that allows therapeutic transactions to occur. King (1981) defined nursing as, “a process of action, reaction, and interaction by which nurse and client share information about their perception in nursing situation.” Nursing is a process of multiple human interactions in a controlled environment where the patient and nurse perceive the other and the situation. Through effective communication, they set goals mutually and explore interventions to achieve the goals. King’s goal of nursing is to help human beings maintain health in order to have normal function in their everyday life (Williams, 2001, p.25). King, I.M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley. Williams, L.A. (2001). Imogene King’s interacting systems theory: Application in emergency and rural nursing. Online Journal of Rural Nursing and Health Care, 2(1). Retrieved from: http://www.rno.org/journal/index.php/online-journal/article/viewFile/93/89

Interpretation and Implication 3 fundamental needs Nurse-patient relationship Stress Goal Attainment and Nursing Process The human being has 3 fundamental needs: The need for health information to make sound decisions; The need for care to prevent ailment: The need for care when they are unable to care for themselves. The nurse-patient relationship starts after perceptions are made. If the nurse-patient relationship is established, transaction will occur. A nurse, with special knowledge and skill base, can provide the patient with information and the means for appropriate goal setting. When transactions are made mutually, goals are attained and satisfaction will occur (King, 1981). Improved health status will also occur as a result of effective transactions. Stress can be present in the external environment if there is a role conflict or misconception of expectations from either the nurse or patient. The nurse has the duty to care for the patient by promoting, maintaining, and restoring health (King, 1981). The nurse should interpret the information and perceptions then communicate expectations to diffuse stress. The professional nurse interprets information in the nursing process in order to plan, implement, and evaluate patient outcomes. The Goal Attainment Theory reflects the nursing process method. Assessment portion includes the interaction with the patient, perceptions made, and communication establishment. Planning portion- Once the nurse has collected data from the assessment, decisions can be made regarding health care goals. Interventions to achieve goals are established mutually when the patient is ready to learn. Implementation includes transactions made toward the goals. Interventions are implemented by both the nurse and the patient. Evaluation considers the question: Was the goal attained? It evaluates the effectiveness of transactions and interventions. King, I.M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley.

Clarification of Origin Review of literature Systems structure; diving whole into parts Goal: Health Unique to Nursing Personal, Interpersonal and Social While Dr. Imogene M. King was working on a master’s program in nursing she began to develop her conceptual framework and theory. She reviewed literature in psychology, sociology, and nursing looking to identify particular trends in health care. During this process she identified with words that consistently reappeared. She began to expand her critical thinking beyond these words to the initial concepts of: interpersonal relations, perception, organization, and energy. She discussed her discoveries with colleagues and at conferences. Eventually King developed a conceptual framework based upon a systems structure; dividing wholes into parts. King found foundations of a system to be comprised of: structure, function, resources, and goals. The goal King identified with was health. This comprised a conceptual framework, more abstract than theory. As King continued in developing this philosophy, unique to nursing, she narrowed her concepts to be grouped into three further systems: personal, interpersonal, and social. Narrowing her concepts she began to develop her Theory of Goal Attainment (Sieloff, 1991). Sieloff, C. L. (1991). Imogene King: A conceptual framework for nursing. Newbury Park, CA: SAGE .

Content Review of global concepts Environment Health Nursing Focus on the person King identifies with each global concept: person, environment, health, and nursing and further expands on each perception. The metaparadigm of health is described by King as “a process of human growth and development (and) relates to the way individuals deal with the stress of growth and development while functioning within the cultural pattern in which they were born and to which they attempt to conform” (King, 1981, p.4). King does not address environment as heavily as the other metaparadigms in her book, which details her nursing theory (Sieloff, 1991). However, King does recognize the role of environment in her model. For example she states, “the internal environment of human beings transforms energy to enable them to adjust to continuous external environmental changes” (King, 1981, p. 5). The global concept of nursing is described by King as promotion, maintenance, and restoration of health, along with the care of the sick, injured, and dying (Sieloff, 1991). Lastly, the metaparadigm of person is the focus of King’s theory, as King’s Personal System focuses on individual human beings within her conceptual framework. King states that people are logical and feeling and they react to expectations, other people, events, and objects. They respond on the basis of their, “perception, expectations, and needs” (King, 1981 p. 20) King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley. Sieloff, C. L. (1991). Imogene King a conceptual framework for nursing. Newbury Park, CA: SAGE .

Concepts and View Inclusive theory Conceptual framework abstract Theory is specific Similar beliefs in other models King’s model is presented as a theory that can be utilized in any type of nursing. Her conceptual framework is abstract, however her theory is specific. Other theorists have attributes in their models that reflect similar beliefs. Scholars of King have declared “Since (the year) 2000, there have been 11 middle-range theories published that are derived from King’s conceptual system” (Clark, Killeen, Messmer, & Leibold Sieloff, 2009, p. 129). Clark, P.N., Killeen, M.B., Messmer, P.R., & Sieloff, C.L. (2009, April). Imogene M. King’s scholars reflect on her wisdom and influence on nursing science. Nursing Science Quarterly, 22(2), 128-133. doi: 10.1177/0894318409332568.

Model in Practice Conceptual System Goal attainment addition Useful in a variety of healthcare settings An example King acknowledged insight “in recognizing that her conceptual system could not directly be applied to practice situations” (Clark, Killeen, Messmer, & Leibold Sieloff, 2009, p. 130). Therefore, she developed her conceptual framework to include the, “middle-range theory of goal attainment that could be used by any nurse in any situation to further improve quality of care (Clark, Killeen, Messmer, & Leibold Sieloff, 2009, p. 129). The result was that Kings model of Goal Attainment is, “timeless and not culture bound (and recognizes) human beings interact with their environment over time” (Plummer & Malzahm, 2009, p. 135). Kings theory can be used by all nurses in various health situations. An example of this would be a nurse working in a physician’s office. Many patients come in for regular check-up’s at which time physicians identify their medical problem(s). An overweight diabetic patient may work with the nurse to develop a plan to achieve the goal of losing weight and maintaining a normal blood sugar. Clark, P.N., Killeen, M.B., Messmer, P.R., & Sieloff, C.L. (2009, April). Imogene M. King’s scholars reflect on her wisdom and influence on nursing science. Nursing Science Quarterly, 22(2), 128-133. doi: 10.1177/0894318409332568. Plummer, M., & Malzahm, A. (2009, April). Quality of life in contemporary nursing theory: A conceptual analysis. Nursing Science Quarterly, 22(2), 134-140. doi: 10.1177/0894318409332807

Case Study Joan was a patient assigned to registered nurse Cindy. Joan was spending her remaining days in a locked Alzheimer’s unit. Cindy was her primary care nurse and new to the Alzheimer’s unit. Cindy’s previous experience was in the rehab unit. In rehab, she easily worked within the framework of Kings Goal Attainment theory. Cindy interacted with her patients developing mutual purposeful goals. Cindy and her patients implemented these plans to achieve these goals. In the Alzheimer’s unit, Cindy felt lost in providing care to Joan.

Case Study continued Joan was unable to verbally communicate her needs. Joan’s disease was degenerative and terminal. Joan occasionally would throw items or attempt to hit other patients and staff when her environmental stimuli was hectic. To complicate Cindy’s dilemma, Joan’s family was quite distraught over the condition of their mother. Once a thriving mother who planned family gatherings, loved to cook, and spoiled her grandchildren, now Joan didn’t appear to recognize her family. Joan’s inability to communicate her needs or desires created a barrier in determining what goal(s), if any, could be mutually decided upon, and implemented.

How could Cindy provide care to Joan in the context of King’s Goal Attainment Theory? Arrange her personal space so that she is able to view pictures of her family, place a quilt she designed on her bed, and narrate stories from her life to her. Have nurse aides provide care because Joan can’t self-perform her ADL’s. Communicate with family members putting together a plan of care that identifies Joan’s current abilities, preferences, and triggers in her behavior. Then develop interventions that promote Joan’s quality of life. Recognize Joan’s abilities, such as the ability to self-ambulate, and develop a plan of care that centers on her capabilities. Ensure Joan has a peaceful quiet surrounding by permanently separating her from other people and activities.

What interventions can you suggest for this scenario that would represent King’s theory and provide a positive outcome? Who can/should be involved in the planning process for interventions for Joan?

References Chitty, K. K., & Black, B. P. (2011). Professional nursing concepts and challenges (6th ed.). Maryland Heights, MO: Saunders Elsevier. Clark, P.N., Killeen, M.B., Messmer, P.R., & Sieloff, C.L. (2009, April). Imogene M. King’s scholars reflect on her wisdom and influence on nursing science. Nursing Science Quarterly, 22(2), 128-133. doi: 10.1177/0894318409332568. King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley.

References Plummer, M., & Malzahm, A. (2009, April). Quality of life in contemporary nursing theory: A conceptual analysis. Nursing Science Quarterly, 22(2), 134-140. doi:10.1177/0894318409332807 Sieloff, C. L. (1991). Imogene King: A conceptual framework for nursing. Newbury Park, CA: SAGE . Williams, L.A. (2001). Imogene King’s interacting systems theory: Application in emergency and rural nursing. Online Journal of Rural Nursing and Health Care, 2(1). Retrieved from: http://www.rno.org/journal/index.php/online- journal/article/viewFile/93/89