King’s Conceptual System Theory

King’s Conceptual System Theory

Assignment Description:

King’s Conceptual System Theory

Write a 1270-1300 word APA paper addressing each of the following points.

Be sure to completely answer all the questions for each bullet point.

Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. King’s Conceptual System Theory

Support your ideas with at least two (2) outside sources and the textbook using citations in your essay.

Make sure to cite using the APA writing style for the essay.

The cover page and reference page in correct APA do not count towards the minimum word amount. Review the rubric criteria for this assignment.

1. Discuss and explain King’s Conceptual System Theory
2. First explain the 3 systems and provide examples of each system
3. Explain how the systems influence goal attainment
4. How could King’s theory help define a clinical quality problem?
5. Apply this theory to a potential practice quality improvement initiative within your clinical practice.
6. How could a quality committee align outcomes with King’s Conceptual System Theory?
7. What additional nursing theory from our readings could also align with an improved quality of practice initiative? King’s Conceptual System Theory

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Chapter 9 – reading assignment for Module 4 assignment.

 

Introducing the Theorist

Imogene M. King was born on January 30, 1923, in West Point, Iowa. She received a diploma in nursing from St. John’s Hospital School of Nursing, St. Louis, Missouri (1945); a bachelor of science in nursing education (1948); a master of science in nursing from St. Louis University (1957); and a doctor of education (EdD) from Teachers College, Columbia University, New York (1961). She held educational, administrative, and leadership positions at St. John’s Hospital School of Nursing, the Ohio State University, Loyola University, the Division of Nursing in the U.S. Department of Health, Education, and Welfare, and the University of South Florida. King’s hallmark theory publications include: “A Conceptual Frame of Reference for Nursing” (1968), Towards a Theory for Nursing: General Concepts of Human Behaviour (1971), and A Theory for Nursing: Systems, Concepts, Process (1981). Since 1981, King has clarified and expanded her conceptual system, her middle-range theory of goal attainment, and the transaction process model in multiple book chapters, articles in professional journals, and presentations. After retiring as professor emerita from the University of South Florida in 1990, King remained an active contributor to nursing’s theoretical development and worked with individuals and groups in developing additional middle range theories, applying her theoretical formulations to various populations and settings and implementing the theory of goal attainment in clinical practice. King received recognition and numerous awards for her distinguished career in nursing from the American Nurses Association, the Florida Nurses Association, the American Academy of Nursing, and Sigma Theta Tau International. King died in December 2007. Her theoretical formulations for nursing continue to be taught at all levels of nursing education and applied and extended by national and international scholars.1 King’s Conceptual System Theory

Overview of the Conceptual System (King’s Conceptual System and Theory of Goal Attainment)

Theoretical Evolution in King’s Own Words

My first theory publication pronounced the problems and prospect of knowledge development in nursing (King, 1964). More than 30 years ago, the problems were identified as (1) lack of a professional nursing language, (2) a theoretical nursing phenomena, and (3) limited concept development. Today, theories and conceptual frameworks have identified theoretical approaches to knowledge development and utilization of knowledge in practice. Concept development is a continuous process in the nursing science movement (King, 1988).

 

My rationale for developing a schematic representation of nursing phenomena was influenced by the Howland systems model (Howland, 1976) and the Howland and McDowell conceptual framework (Howland & McDowell, 1964). The levels of interaction in those works influenced my ideas relative to organizing a conceptual frame of reference for nursing. Because concepts offer one approach to structure knowledge for nursing, a thorough review of nursing literature provided me with ideas to identify five comprehensive concepts as a basis for a conceptual system for nursing. The overall concept is a human being, commonly referred to as an “individual” or a “person.” Initially, I selected abstract concepts of perception, communication, interpersonal relations, health, and social institutions (King, 1968). These ideas forced me to review my knowledge of philosophy relative to the nature of human beings (ontology) and to the nature of knowledge (epistemology). King’s Conceptual System Theory

Philosophical Foundation

In the late 1960s, while auditing a series of courses in systems research, I was introduced to a philosophy of science called general system theory (von Bertalanffy, 1968). This philosophy of science gained momentum in the 1950s, although its roots date to an earlier period. This philosophy refuted logical positivism and reductionism and proposed the idea of isomorphism and perspectivism in knowledge development. Von Bertalanffy, credited with originating the idea of general system theory, defined this philosophy of science movement as a “general science of wholeness: systems of elements in mutual interaction” (von Bertalanffy, 1968, p. 37).

 

My philosophical position is rooted in general system theory, which guides the study of organized complexity as whole systems. This philosophy gave me the impetus to focus on knowledge development as an informationprocessing, goal-seeking, and decision-making system. General system theory provides a holistic approach to study nursing phenomena as an open system and frees one’s thinking from the parts-versus-whole dilemma. In any discussion of the nature of nursing, the central ideas revolve around the nature of human beings and their interaction with internal and external environments. During this journey, I began to conceptualize a theory for nursing. However, because a manuscript was due in the publisher’s office, I organized my ideas into a conceptual system (formerly called a “conceptual framework”), and the result was the publication of a book titled Toward a Theory of Nursing (King, 1971).

 

Design of a Conceptual System

A conceptual system provides structure for organizing multiple ideas into meaningful wholes. From my initial set of ideas in 1968 and 1971, my conceptual framework was refined to show some unity and relationships among the concepts. The conceptual system consists of individual systems, interpersonal systems, and social systems and concepts that are important for understanding the interactions within and between the systems (Fig. 9-1). King’s Conceptual System Theory

 

The next step in this process was to review the research literature in the discipline in which the concepts had been studied. For example, the concept of perception has been studied in psychology for many years. The literature indicated that most of the early studies dealt with sensory perception. Around the 1950s, psychologists began to study interpersonal perception, which related to my ideas about interactions. From this research literature, I identified the characteristics of perception and defined the concept for my framework. I continued searching literature for knowledge of each of the concepts in my framework. An update on my conceptual system was published in 1995 (King, 1995).

Process for Development of Concepts

“Searching for scientific knowledge in nursing is an ongoing dynamic process of continuous identification, development, and validation of relevant concepts” (King, 1975, p. 25). What is a concept? A concept is an organization of reference points. Words are the verbal symbols used to explain events and things in our environment and relationships to past experiences. Northrop (1969) noted: “[C]oncepts fall into different types according to the different sources of their meaning…. A concept is a term to which meaning has been assigned.” Concepts are the categories in a theory. King’s Conceptual System Theory

 

The concept development and validation process is as follows:

 

1. Review, analyze, and synthesize research literature related to the concept.

 

2. From the review, identify the characteristics (attributes) of the concept.

 

3. From the characteristics, write a conceptual definition.

 

4. Review literature to select an instrument or develop an instrument.

 

5. Design a study to measure the characteristics of the concept.

 

6. Select the population to be sampled.

 

7. Collect data.

 

8. Analyze and interpret data.

 

9. Write results of findings and conclusions.

 

10. State implications for adding to nursing knowledge.

 

Concepts that represent phenomena in nursing are structured within a framework and theory to show relationships.

 

Multiple concepts were identified from my analysis of nursing literature (King, 1981). The concepts that provided substantive knowledge about human beings (self, body image, perception, growth and development, learning, time, and personal space) were placed within the personal system, those related to small groups (interaction, communication, role, transactions, and stress) were placed within the interpersonal system, and those related to large groups that make up a society (decision making, organization, power, status, and authority) were placed within the social system (King, 1995). However, knowledge from all of the concepts is used in nurses’ interactions with individuals and groups within social organizations, such as the family, the educational system, and the political system. Knowledge of these concepts came from my synthesis of research in many disciplines. Concepts, when defined from research literature, give nurses knowledge that can be applied in the concrete world of nursing. The concepts represent basic knowledge that nurses use in their role and functions either in practice, education, or administration. In addition, the concepts provide ideas for research in nursing. King’s Conceptual System Theory

 

One of my goals was to identify what I call the essence of nursing. That brought me back to the question: What is the nature of human beings? A vicious circle? Not really! Because nurses are first and foremost human beings who give nursing care to other human beings, my philosophy of the nature of human beings has been presented along with assumptions I have made about individuals (King, 1989a). Recognizing that a conceptual system represents structure for a discipline, the next step in the process of knowledge development was to derive one or more theories from this structure.

 

Lo and behold, a theory of goal attainment was developed (King, 1981, 1992). More recently, others have derived theories from my conceptual system (Frey & Sieloff, 1995).

 

Theory of Goal Attainment

Generally speaking, nursing care’s goal is to help individuals maintain health or regain health (King, 1990). Concepts are essential elements in theories. When a theory is derived from a conceptual system, concepts are selected from that system. Remember my question: What is the essence of nursing? The concepts of self, perception, communication, interaction, transaction, role, growth and development, stress, time, and personal space were selected for the theory of goal attainment.

 

Transaction Process Model

A transaction model, shown in Figure 9-2, was developed that represented the process in which individuals interact to set goals that result in goal attainment (King, 1981, 1995).

The model is a human process that can be observed in many situations when two or more people interact, such as in the family and in social events (King, 1996). As nurses, we bring knowledge and skills that influence our perceptions, communications, and interactions in performing the functions of the role. In your role as a nurse, after interacting with a patient, sit down and write a description of your behavior and that of the patient. It is my belief that you can identify your perceptions, mental judgments, mental action, and reaction (negative or positive). Did you make a transaction? That is, did you exchange information and set a goal with the patient? Did you explore the means for the patient to use to achieve the goal? Was the goal achieved? If not, why? It is my opinion that most nurses use this process but are not aware that it is based in a nursing theory. With knowledge of the concepts and of the process, nurses have a scientific base for practice that can be clearly articulated and documented to show quality care. How can a nurse document this transaction model in practice? King’s Conceptual System Theory

 

Documentation System

A documentation system was designed to implement the transaction process that leads to goal attainment (King, 1984). Most nurses use the nursing process to assess, diagnose, plan, implement, and evaluate, which I call a method. My transaction process provides the theoretical knowledge base to implement this method. For example, as one assesses the patient and the environment and makes a nursing diagnosis, the concepts of perception, communication, and interaction represent knowledge the nurse uses to gather information and make a judgment. A transaction is made when the nurse and patient decide mutually on the goals to be attained, agree on the means to attain goals that represent the plan of care, and then implement the plan. Evaluation determines whether or not goals were attained. If not, you ask why, and the process begins again. The documentation is recorded directly in the patient’s chart. The patient’s record indicates the process used to achieve goals. On discharge, the summary indicates goals set and goals achieved. One does not need multiple forms when this documentation system is in place, and the quality of nursing care is recorded. Why do nurses insist on designing critical paths, various care plans, and other types of forms when, with knowledge of this system, the nurse documents nursing care directly on the patient’s chart? Why do we use multiple forms to complicate a process that is knowledge-based and also provides essential data to demonstrate outcomes and to evaluate quality nursing care?

 

Federal laws have been passed that indicate that patients must be involved in decisions about their care and about dying. This transaction process provides a scientifically based process to help nurses implement federal laws such as the Patient Self-Determination Act (Federal Register, 1995).

 

Goal Attainment Scale

Analysis of nursing research literature in the 1970s revealed that few instruments were designed for nursing research. In the late 1980s, the faculty at the University of Maryland, experts in measurement and evaluation, applied for and received a grant to conduct conferences to teach nurses to design reliable and valid instruments. I had the privilege of participating in this 2-year continuing education conference, where I developed a Goal Attainment Scale (King, 1989b). This instrument may be used to measure goal attainment. It may also be used as an assessment tool to provide patient data to plan and implement nursing care. King’s Conceptual System Theory

 

Vision for the Future

My vision for the future of nursing is that nursing will provide access to health care for all citizens. The United States’ health-care system will be structured using my conceptual system. Entry into the system will be via nurses’ assessment so that individuals are directed to the right place in the system for nursing care, medical care, social services information, health teaching, or rehabilitation. My transaction process will be used by every practicing nurse so that goals can be achieved to demonstrate quality care that is cost-effective. My conceptual system, theory of goal attainment, and transaction process model will continue to serve a useful purpose in delivering professional nursing care. The relevance of evidence-based practice, using my theory, joins the art of nursing of the 20th century to the science of nursing in the 21st century.

 

Concepts and Middle-Range Theory Development Within King’s Conceptual System or the Theory of Goal Attainment

Concept development within a conceptual framework is particularly valuable, as it often explicates concepts more clearly than a theorist may have done in his or her original work. Concept development may also demonstrate how other concepts of interest to nursing can be examined through a nursing lens. Such explication further assists the development of nursing knowledge by enabling the nurse to better understand the application of the concept within specific practice situations. Examples of concepts developed from within King’s work include the following: collaborative alliance relationship (Hernandez, 2007); decision making (Ehrenberger, Alligood, Thomas, Wallace, & Licavoli, 2007), empathy (May, 2007), holistic nursing (Li, Li, & Xu, 2010), managerial coaching (Batson & Yoder, 2012), patient satisfaction with nursing care (Killeen, 2007), sibling closeness (Lehna, 2009), and whole person care (Joseph, Laughon, & Bogue, 2011).2

 

Applications of the Theory in Practice

Since the first publication of King’s work (1971), nursing’s interest in the application of her work to practice has grown. The fact that she was one of the few theorists who generated both a framework and a middle range theory further expanded her work. Today, new publications related to King’s work are a frequent occurrence. Additional middle-range theories have been generated and tested, and applications to practice have expanded. After her retirement, King continued to publish and examine new applications of the theory. The purpose of this part of the chapter is to provide an updated review of the state of the art in terms of the application of King’s conceptual system (KCS) and middle-range theory in a variety of areas: practice, administration, education, and research. Publications, identified from a review of the literature, are summarized and briefly discussed. Finally, recommendations are made for future knowledge development in relation to KCS and middle-range theory, particularly in relation to the importance of their application within an evidence-based practice environment. King’s Conceptual System Theory

 

In conducting the literature review, the authors began with the broadest category of application—application within KCS to nursing care situations. Because a conceptual framework is, by nature, very broad and abstract, it can serve only to guide, rather than to prescriptively direct, nursing practice.

 

Development of middle-range theories is a natural extension of a conceptual framework. Middle-range theories, clearly developed from within a conceptual framework, accomplish two goals: (1) Such theories can be directly applied to nursing situations, whereas a conceptual framework is usually too abstract for such direct application, and (2) validation of middle-range theories, clearly developed within a particular conceptual framework, lends validation to the conceptual framework itself. King (1981) stated that individuals act to maintain their own health. Although not explicitly stated, the converse is probably true as well: Individuals often do things that are not good for their health. Accordingly, it is not surprising that the KCS and related middle-range theory are often directed toward patient and group behaviors that influence health.

 

In addition to the middle-range theory of goal attainment (King, 1981), several other middle-range theories have been developed from within King’s interacting systems framework. In terms of the personal system, Brooks and Thomas (1997) used King’s framework to derive a theory of perceptual awareness. The focus was to develop the concepts of judgment and action as core concepts in the personal system. Other concepts in the theory included communication, perception, and decision making.

 

In relation to the interpersonal system, several middle-range theories have been developed regarding families. Doornbos (2007), using her family health theory, addressed family health in terms of families of adults with persistent mental illness. Thomason and Lagowski (2008) used concepts from King along with other nursing theorists to develop a model for collaboration through reciprocation in health-care organizations. In relation to social systems, Sieloff and Bularzik (2011) revised the “theory of group power within organizations” to the “theory of group empowerment within organizations” to assist in explaining the ability of groups to empower themselves within organizations.3

 

Review of the literature identified instruments specifically designed within King’s framework. King (1988) developed the Health Goal Attainment instrument, designed to detail the level of attainment of health goals by individual clients. The Nurse Performance Goal Attainment (NPGA) was developed by Kameoka, Funashima, and Sugimori (2007).

 

Applications in Nursing Practice

There have been many applications of King’s middle-range theory to nursing practice because the theory focuses on concepts relevant to all nursing situations—the attainment of client goals. The application of the middle-range theory of goal attainment (King, 1981) is documented in several categories: (1) general application of the theory, (2) exploring a particular concept within the context of the theory of goal attainment, (3) exploring a particular concept related to the theory of goal attainment, and (4) application of the theory in nonclinical nursing situations. For example, King (1997) described the use of the theory of goal attainment in nursing practice. Short-term group psychotherapy was the focus of theory application for Laben, Sneed, and Seidel (1995). D’Souza, Somayaji, and Subrahmanya (2011) used the theory to “examine determinants of reproductive health and related quality of life among Indian women in mining communities” (p. 1963).

 

Nursing Process and Nursing Terminologies, Including Standardized Nursing Languages

Within the nursing profession, the nursing process has consistently been used as the basis for nursing practice. King’s framework and middle-range theory of goal attainment (1981) have been clearly linked to the process of nursing. Although many published applications have broad reference to the nursing process, several deserve special recognition. First, King herself (1981) clearly linked the theory of goal attainment to nursing process as theory and to nursing process as method. Application of King’s work to nursing curricula further strengthened this link.

 

In addition, the steps of the nursing process have long been integrated within the KCS and the middle-range theory of goal attainment (Daubenmire & King, 1973; D’Souza, Somayaji, & Suybrahmanya, 2011; Woods, 1994). In these process applications, assessment, diagnosis, and goal-setting occur, followed by actions based on the nurse–client goals. The evaluation component of the nursing process consistently refers back to the original goal statement(s). In related research, Frey and Norris (1997) also drew parallels between the processes of critical thinking, nursing, and transaction. King’s Conceptual System Theory

 

Over time, nursing has developed nursing terminologies that are used to assist the profession to improve communication both within, and external to, the profession. These terminologies include the nursing diagnoses, nursing interventions, and nursing outcomes. With the use of these standardized nursing languages (SNLs), the nursing process is further refined. Standardized terms for diagnoses, interventions, and outcomes also potentially improve communication among nurses.

 

Using SNLs also enables the development of middle-range theory by building on concepts unique to nursing, such as those concepts of King that can be directly applied to the nursing process: action, reaction, interaction, transaction, goal setting, and goal attainment. Biegen and Tripp-Reimer (1997) suggested middle-range theories be constructed from the concepts in the taxonomies of the nursing languages focusing on outcomes. Alternatively, King’s framework and theory may be used as a theoretical basis for these phenomena and may assist in knowledge development in nursing in the future.

 

With the advent of SNLs, “outcome identification” is identified as a step in the nursing process after assessment and diagnosis (McFarland & McFarland, 1997, p. 3). King’s (1981) concept of mutual goal setting is analogous to the outcomes identification step, because King’s concept of goal attainment is congruent with the evaluation of client outcomes.

 

In addition, King’s concept of perception (1981) lends itself well to the definition of client outcomes. Moorhead, Johnson, and Maas (2013) define a nursing-sensitive patient outcome as “an individual, family or community state, behaviour or perception that is measured along a continuum in response to nursing intervention(s)” (p. 2). This is fortuitous because the development of nursing knowledge requires the use of client outcome measurement. The use of standardized client outcomes as study variables increases the ease with which research findings can be compared across settings and contributes to knowledge development. Therefore, King’s concept of mutually set goals may be studied as “expected outcomes.” Also, by using SNLs, King’s (1981) middle-range theory of goal attainment can be conceptualized as the “attainment of expected outcomes” as the evaluation step in the application of the nursing process.

 

In summary, although these terminologies, including SNLs, were developed after many of the original nursing theorists had completed their works, nursing frameworks such as the KCS (1981) can still find application and use within the terminologies. In addition, it is this type of application that further demonstrates the framework’s utility across time. For example, Chaves and Araujo (2006), Ferreira De Sourza, Figueiredo De Martino, and Daena De Morais Lopes (2006), Goyatá, Rossi, and Dalri (2006),  and Palmer (2006) implemented nursing diagnoses within the context of King’s framework.4 King’s Conceptual System Theory

 

Applications in Client Systems

KCS and middle-range theory of goal attainment have a long history of application with large groups or social systems (organizations, communities). The earliest applications involved the use of the framework and theory to guide continuing education (Brown & Lee, 1980) and nursing curricula (Daubenmire, 1989; Gulitz & King, 1988). More contemporary applications address a variety of organizational settings. For example, the framework served as the basis for the development of a middle-range theory relating to practice in a nursing home (Zurakowski, 2007). Nwinee (2011) used King’s work, along with Peplau’s, to develop the sociobehavioral self-care management nursing model (p. 91). In addition, the theory of goal attainment has been proposed as the practice model for case management (Hampton, 1994; Tritsch, 1996). These latter applications are especially important because they may be the first use of the framework by other disciplines.

 

Applicable to administration and management in a variety of settings, a middle-range theory of group power within organizations has been developed and revised to the theory of group empowerment within organizations (Sieloff, 1995, 2003, 2007; Sieloff & Dunn, 2008; Sieloff & Bularzik, 2011). Educational settings, also considered as social systems, have been the focus of application of King’s work (George, Roach, & Andfrade, 2011; Greef, Strydom, Wessels, & Schutte, 2009; Ritter, 2008).5

 

Multidisciplinary Applications

Because of King’s emphasis on the attainment of goals and the relevancy of goal attainment to many disciplines, both within and external to health care, it is reasonable to expect that King’s work can find application beyond nursing-specific situations. Two specific examples of this include the application of King’s work to case management (Hampton, 1994; Sowell & Lowenstein, 1994) and to managed care (Hampton, 1994). Both case management and managed care incorporate multiple disciplines as they work to improve the overall quality and cost-efficiency of the health care provided. These applications also address the continuum of care, a priority in today’s health-care environment. Specific researchers (Fewster-Thuente & Velsor-Friedrich, 2008; Khowaja, 2006) detailed their research related to multidisciplinary activities and interdisciplinary collaborations, respectively.6

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Multicultural Applications

Multicultural applications of KCS and related theories are many. Such applications are particularly critical because many theoretical formulations are limited by their culture-bound nature. Several authors specifically addressed the utility of King’s framework and theory for transcultural nursing. Spratlen (1976) drew heavily from King’s framework and theory to integrate ethnic cultural factors into nursing curricula and to develop a culturally oriented model for mental health care. Key elements derived from King’s work were the focus on perceptions and communication patterns that motivate action, reaction, interaction, and transaction. Rooda (1992) derived propositions from the midrange theory of goal attainment as the framework for a conceptual model for multicultural nursing.

 

Cultural relevance has also been demonstrated in reviews by Frey, Rooke, Sieloff, Messmer, and Kameoka (1995) and Husting (1997). Although Husting identified that cultural issues were implicit variables throughout King’s framework, particular attention was given to the concept of health, which, according to King (1990), acquires meaning from cultural values and social norms. King’s Conceptual System Theory

 

Undoubtedly, the strongest evidence for the cultural utility of King’s conceptual framework and midrange theory of goal attainment (1981) is the extent of work that has been done in other cultures. Applications of the framework and related theories have been documented in the following countries beyond the United States: Brazil (Firmino, Cavalcante, & Celia, 2010), Canada (Plummer & Molzahn, 2009), China (Li, Li, & Xu, 2010), India (D’Souza, Somayaji, & Subrahmanya, 2011; George et al., 2011), Japan (Kameoka et al., 2007), Portugal (Chaves & Araujo, 2006; Goyatá et al., 2006; Pelloso & Tavares, 2006), Slovenia (Harih & Pajnkihar, 2009), Sweden (Rooke, 1995a, 1995b), and West Africa (Nwinee, 2011). In Japan, a culture very different from the United States with regard to communication style, Kameoka (1995) used the classification system of nurse–patient interactions identified within the theory of goal attainment (King, 1981) to analyze nurse–patient interactions. In addition to research and publications regarding the application of King’s work to nursing practice internationally, publications by and about King have been translated into other languages, including Japanese (King, 1976, 1985; Kobayashi, 1970). Therefore, perception and the influence of culture on perception were identified as strengths of King’s theory.

 

Research Applications in Varied Settings and Populations

KCS has been used to guide nursing practice and research in multiple settings and with multiple populations. For example, Harih and Pajnkihar (2009) applied King’s model in treating elderly diabetes patients. Joseph et al. (2011) examined the implementation of whole-person care.7 As stated previously, diseases or diagnoses are often identified as the focus for the application of nursing knowledge. Maloni (2007) and Nwinee (2011) conducted research with patients with diabetes, and women with breast cancer were the focus of the work of Funghetto, Terra, and Wolff (2003). In addition, clients with chronic obstructive pulmonary disease were involved in research by Wicks, Rice, and Talley (2007). Clients experiencing a variety of psychiatric concerns have also been the focus of work, using King’s conceptualizations (Murray & Baier, 1996; Schreiber, 1991). Clients’ concerns ranged from psychotic symptoms (Kemppainen, 1990) to families experiencing chronic mental illness (Doornbos, 2007), to clients in short-term group psychotherapy (Laben, Sneed, & Seidel, 1995).8 The theory has also been applied in nonclinical nursing situations. Secrest, Iorio, and Martz (2005) used the theory in examining the empowerment of nursing assistants. Li et al. (2010) explored the “development of the concept of holistic nursing” (p. 33).9

 

Research Applications with Clients Across the Life Span

Additional evidence of the scope and usefulness of King’s framework and theory is its use with clients across the life span. Several applications have targeted high-risk infants (Frey & Norris, 1997; Syzmanski, 1991). Frey (1993, 1995, 1996) developed and tested relationships among multiple systems with children, youth, and young adults. Lehna (2009) explicated the concept of sibling closeness in a study of siblings experiencing a major burn trauma. Interestingly, these studies considered personal systems (infants), interpersonal systems (parents, families), and social systems (the nursing staff and hospital environment). Clearly, a strength of King’s framework and theory is its utility in encompassing complex settings and situations.

 

KCS and the midrange theory of goal attainment have also been used to guide practice with adults (young adults, adults, mature adults) with a broad range of concerns. Goyatá et al. (2006) used King’s work in their study of adults experiencing burns. Additional examples of applications focusing on adults include individuals with hypertension (Firmino et al., 2010) and perceptions of students toward obesity (Ongoco, 2012). Gender-specific work included Sharts-Hopko’s (2007) use of a middle-range theory of health perception to study the health status of women during menopause transition and Martin’s (1990) application of the framework toward cancer awareness among males.

 

Several of the applications with adults have targeted the mature adult, thus demonstrating contributions to the nursing specialty of gerontology. Reed (2007) used a middle-range theory to examine the relationship of social support and health in older adults. Harih and Pajnkihar (2009) applied “King’s model in the treatment of elderly diabetes patients” (p. 201). Clearly, these applications, and others, show how the complexity of King’s framework and midrange theory increases its usefulness for nursing.10

 

Research Applications to Client Systems

In addition to discussing client populations across the life span, client populations can be identified by focus of care (client system) and/or focus of health problem (phenomenon of concern). The focus of care, or interest, can be an individual (personal system) or group (interpersonal or social system). Thus, application of King’s work, across client systems, can be divided into the three systems identified within the KCS (1981): personal (the individual), interpersonal (small groups), and social (large groups/society).

 

Use with personal systems has included both patients and nurses. LaMar (2008) examined nurses in a tertiary acute care organization as the personal system of interest. Nursing students as personal systems were the focus of Lockhart and Goodfellow’s research (2009). When the focus of interest moves from an individual to include interaction between two people, the interpersonal system is involved. Interpersonal systems often include clients and nurses. An example of an application to a nurse–client dyad is Langford’s (2008) study of the perceptions of transactions with nurse practitioners and obese adolescents. In relation to interpersonal systems, or small groups, many publications focus on the family. Frey and Norris (1997) used both KCS and the theory of goal attainment in planning care with families of premature infants. Alligood (2010) described “family health care with King’s theory of goal attainment” (p. 99). King’s Conceptual System Theory

 

Research Applications Focusing on Phenomena of Concern to Clients

Within King’s work, it is critically important for the nurse to focus on, and address, the phenomenon of concern to the client. Without this emphasis on the client’s perspective, mutual goal setting cannot occur. Hence, a client’s phenomenon of concern was selected as neutral terminology that clearly demonstrated the broad application of King’s work to a wide variety of practice situations. A topic that frequently divides nurses is their area of specialty. However, by using a consistent framework across specialties, nurses may be able to focus more clearly on their commonalities, rather than highlighting their differences.11 A review of the literature clearly demonstrates that King’s framework and related theories have application within a variety of nursing specialties.12 This application is evident whether one is reviewing a “traditional” specialty, such as surgical nursing (Bruns, Norwood, Bosworth, & Gill, 2009; Lockhart & Goodfellow, 2009; Sivaramalingam, 2008), or the nontraditional specialties of forensic nursing (Laben et al., 1991) and/or nursing administration (Gianfermi & Buchholz, 2011; Joseph et al., 2011).

 

Health is one area that certainly binds clients and nurses. Improved health is clearly the desired end point, or outcome, of nursing care and something to which clients aspire. Review of the outcome of nursing care, as addressed in published applications, tends to support the goal of improved health directly and/or indirectly, as the result of the application of King’s work. Health status is explicitly the outcome of concern in practice applications by Smith (1988). Several applications used health-related terms. For example, DeHowitt (1992) studied well-being, and D’Souza et al. (2011) examined the determinants of health.

 

Health promotion has also been an emphasis for the application of King’s ideas. Sexual counseling was the focus of work by Villeneuve and Ozolins (1991). Health behaviors were Hanna’s (1995) focus of study, and Plummer and Molzahn (2009) explored the “quality of life in contemporary nursing theory” (p. 134). Frey (1996, 1997) examined both health behaviors and illness management behaviors in several groups of children with chronic conditions as well as risky behaviors (1996). Recently, researchers have explored weight loss and obesity (Langford, 2008; Ongoco, 2012).

 

Research Applications in Varied Work Settings

An additional potential source of division within the nursing profession is the work sites where nursing is practiced and care is delivered. As the delivery of health care moves from the acute care hospital to community-based agencies and clients’ homes, it is important to highlight commonalities across these settings, and it is important to identify that King’s framework and middle-range theory of goal attainment continue to be applicable. Although many applications tend to be with nurses and clients in traditional settings, successful applications have been shown across other, including newer and nontraditional settings. From hospitals (Bogue, Jospeh, & Sieloff, 2009; Firmino et al., 2010; Kameoka et al., 2007) to nursing homes (Zurakowski, 2007), King’s framework and related theories provide a foundation on which nurses can build their practice interventions. In addition, the use of the KCS and related theories are evident within quality improvement projects (Anderson & Mangino, 2006; Durston, 2006; Khowaja, 2006).13 Nurses also use the theory of goal attainment (King, 1981) to examine concepts related to the theory. This application was demonstrated by Smith (2003), by Jones and Bugge (2006), by Sivaramalingam (2008) in a study of patients’ perceptions of nurses’ roles and responsibilities, and by Mardis (2012) in a study of patients’ perceptions of minimal lift equipment. King’s Conceptual System Theory

 

Relationship to Evidence-Based Practice

From an evidence-based practice and King perspective, the profession must implement three strategies to apply theory-based research findings effectively. First, nursing as a discipline must agree on rules of evidence in evaluation of quality research that reflect the unique contribution of nursing to health care. Second, the nursing rules of evidence must include heavier weight for research that is derived from, or adds to, nursing theory. Third, the nursing rules of evidence must reflect higher scores when nursing’s central beliefs are affirmed in the choice of variables. This third strategy, for the use of concepts central to nursing, has clear relevance for evidence-based practice when using King’s (1981) concepts as reformulated within interventions or outcomes. Outcomes, as in King’s concept of goal attainment, provide data for evidence-based practice.

 

Currently, safety and quality initiatives in organizations, with evidence-based practice as the innovation, use many concepts initially defined by King and found in middle-range theories (Sieloff & Frey, 2007). King’s (1981) work on the concepts of client and nurse perceptions, and the achievement of mutual goals has been assimilated and accepted as core beliefs of the discipline of nursing. Research conducted with a King theoretical base is well positioned for application by nurse caregivers (Bruns et al., 2009; Gemmill et al., 2011; Mardis, 2011), nurse administrators (Sieloff & Bularzik, 2011), and client-consumers (Killeen, 2007) as part of evolving evidence-based nursing practice.14

 

Recommendations for Future Applications Related to King’s Framework and Theory

Obviously, new nursing knowledge has resulted from applications of King’s framework and theory. However, nursing is evolving as a science. Additional work continues to be needed. On the basis of a review of the applications previously discussed, recommendations for future applications continue to focus on (1) the need for evidence-based nursing practice that is theoretically derived; (2) the integration of King’s work in evidence-based nursing practice; (3) the integration of King’s concepts within SNLs; (4) analysis of the future effect of managed care, continuous quality improvement, and technology on King’s concepts; (5) identification, or development and implementation, of additional relevant instruments; and (6) clarification of effective nursing interventions, including identification of relevant Nursing Interventions Classifications, based on King’s work.

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As part of its mission, the King International Nursing Group (KING) (www.kingnursing.org) continuously monitors the latest publications and research based on King’s work and related theories, providing updates to members. To further assist in the dissemination of such research, KING also conducts a biannual research conference. The following Exemplar illustrates the application of the theory of goal attainment to an interdisciplinary team, quality improvement, and evidence-based practice.

 

PRACTICE EXEMPLAR

Provided by Mary B. Killeen, PhD, RN, NEA-BC

Claire Smith, RN, BSN, is a recent nursing graduate in her first position on a medical intensive care unit in a suburban community hospital. Claire’s manager suggests that she should join the unit’s interdisciplinary quality improvement committee to develop her leadership skills. The goal of the committee is to improve patient care by using the best available evidence to develop and implement practice protocols.

 

At the first meeting, Claire was asked if she had any burning clinical questions as a new graduate. She stated that she was taught to avoid use of normal saline for tracheal suctioning. However, she noticed many respiratory therapists and some nurses routinely using normal saline with suctioning. When asked about this practice, she was told that normal saline was useful to break up secretions and aid in their removal. The committee affirmed Claire’s observation of contradictory practices between what is taught and what is done in practice. After discussion, the group formulated the following clinical question: Does instilling normal saline decrease favorable patient outcomes among patients with endotracheal tubes or tracheostomies? King’s Conceptual System Theory

 

Claire suggests to the committee that King’s theory of goal attainment might be useful as a theoretical guide for this project because the question is focused on patient outcomes, or according to King’s theory, goals. The nursing members are familiar with King’s theory, and all members value using theory to guide practice. Claire’s proposal is accepted. Claire experienced working on EBP group projects as a student, so she feels comfortable volunteering to develop a draft of the theoretical foundation for the project. Two other committee members agree to work on the plan and present it at the next meeting.

 

The following are the questions and the conclusions that Claire and her colleagues discussed:

 

1. How does King’s theory of goal attainment help the unit’s quality improvement (QI) committee?

 

Goal attainment theory is derived from KCS, which includes personal, interpersonal, and social systems. The QI committee is a type of interpersonal system. An interpersonal system encompasses individuals in groups interacting to achieve goals. The QI committee is engaged in the committee’s goal attainment for the benefit of patients. “Role expectations and role performance of nurses and clients influence transactions” (King, 1981, p. 147). When used in interdisciplinary teams, the transaction process in King’s theory facilitates mutual goal setting with nurses, and ultimately patients, based on each member of the team’s specific knowledge and functions.

 

Multidisciplinary care conferences, an example of a situation where goal-setting among professionals occurs, is a label for an indirect nursing intervention within the Nursing Interventions Classification (NIC; Bulechek, Butcher, & Dochterman, 2008). Some of the activities listed under this NIC reflect King’s (1981) concepts: “establish mutually agreeable goals; solicit input for patient care planning; revise patient care plan, as necessary; discuss progress toward goals; and provide data to facilitate evaluation of patient care plan” (p. 501).

 

2. How does King define goals and goal attainment and how are these related to quality patient outcomes?

 

According to King’s theory of goal attainment (1981), goals are mutually agreed upon, and through a transaction process, are attained. Goals are similar to outcomes that are achieved after agreement on the definitions and measurement of the outcomes. Quality improvement has shown agreement that evaluation of care must include process and outcomes. Outcomes are the results of interventions or processes. The term “outcome” assumes that a process is central to effective care. An outcome is defined as a change in a patient’s health status. Effectiveness of care can be measured by whether the patient goals (i.e., outcomes) have been attained. The QI Committee engages in goal attainment through communication by setting goals, exploring means, and agreeing on means to achieve goals. In this example, members will gather information, examine data and evidence, interpret the information, and participate in developing a protocol for patients to achieve quality patient outcomes, that is, goals.

 

3. How does King’s theory of goal attainment provide a theoretical foundation for the clinical problem of using normal saline with suctioning?

 

First, the use of King’s theory will help guide the literature search to include studies that address interventions or processes that lead to favorable patient outcomes or goals among patients similar to the population on the unit. Claire’s subgroup enlisted the help of the hospital librarian in searching the literature using the elements of the clinical question and the theoretical concepts as key words. Second, the theoretical formulation of the study helps organize the implementation and evaluation plans so they are attainable.

 

4. What key words would you use for the search considering the clinical question and King’s theory?

 

Key words used are endotracheal tubes, tracheostomies, normal saline, suctioning, outcomes, King’s theory of goal attainment, and goal attainment.

 

5. How does a theoretical foundation, such as King’s theory of goal attainment, apply to a quality improvement or EBP project? King’s Conceptual System Theory

 

Claire used these criteria from her nursing program to develop a theoretical foundation for the project.

 

The theoretical foundation for the project was presented to the committee and accepted.

What were the results of the committee’s work?

 

The search strategy included MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and TRIP databases. All types of evidence (nonexperimental, experimental, qualitative studies, systematic reviews) were included. The evidence was evaluated by the QI committee and included physiological and psychological effects of instillation of normal saline. The collective evidence, relevant to their unit’s practice problem, did not support the routine use of normal saline with suctioning (similar to Halm & Kriski-Hagel, 2008). From the evidence, the committee selected the specific outcomes to track for the project: sputum recovery, oxygenation, and subjective symptoms of pain, anxiety, and dyspnea. Owing to anticipated small samples, hemodynamic alterations and infections were not selected as outcomes. The committee devised a theory-based implementation plan to discontinue normal saline for suctioning using the five Ws (who, what, where, when, why) and how as the outline for the plan. Change processes were employed in the plan. Evaluation of the attainment of outcomes will address the effectiveness of the plan using the measurable outcomes and the degree to which they were attained.

 

■   Summary

An essential component in the analysis of conceptual frameworks and theories is the consideration of their adequacy (Ellis, 1968). Adequacy depends on the three interrelated characteristics of scope, usefulness, and complexity. Conceptual frameworks are broad in scope and sufficiently complex to be useful for many situations. Theories, on the other hand, are narrower in scope, usually addressing less abstract concepts, and are more specific in terms of the nature and direction of relationships and focus.

 

King fully intended her conceptual system for nursing to be useful in all nursing situations. Likewise, the middle-range theory of goal attainment (King, 1981) has broad scope because interaction is a part of every nursing encounter. Although previous evaluations of the scope of King’s framework and middle-range theory have resulted in mixed reviews (Austin & Champion, 1983; Carter & Dufour, 1994; Frey, 1996; Jonas, 1987; Meleis, 2012), the nursing profession has clearly recognized their scope and usefulness. In addition, the variety of practice applications evident in the literature clearly attests to the complexity of King’s work. As researchers continue to integrate King’s theory and framework with the dynamic health-care environment, future applications involving evidence-based practice will continue to demonstrate the adequacy of King’s work in nursing practice. King’s Conceptual System Theory