A Report on Imogene King’s Theory

A requirement submitted
To the subject
Theoretical Foundations of Nursing

By:
AQUISIO, Ribelyne Loise
GAERLAN, Lhaveryll
SERNADILLA, Allen

SEPTEMBER 2018
 HISTORY
Diploma in Nursing, 1945
 St. John’s Hospital School of
Contributions to NANDA
Nursing
International
> St. Louis Missouri
(span of 40 years)
Bachelor (1948) and Masters (1957) of
Participant at the First National
Science Degree in Nursing
Conference on the classification
 St. Louis University of Nursing Diagnoses in St.
Doctor of Education Degree,1961 Louis, 1973
 Teacher’s College of Columbia Died on December 24, 2007
University (age of 84)
Honorary Doctor of Philosophy
Degree,1980
 Southern Illinois University
Received American Nurses Association, Imogen King
Jessie M. Scott Award, 1996
> For her Contributions to
demonstrating the
interrelationships among
nursing practice,
education and research

Background of the theory

Overview of Imogene King’s “Conceptual System and Theory

of Goal Attainment”
 o King’s Conceptual system is based on
the assumption that human beings are
the focus of Nursing. The goal of
nursing is health promotion
maintenance, and/or restoration; care of Transaction will occur
the sick or injured; and care of the dying
(King, 1992) If nurse and client make transaction,
o King states that “nursing’s domain
involves human beings, families, and
communities as a framework within Goal will be attained
which nurse make transactions in
multiple environments with health as a
If goals are attained,
goal”
o The link between interactions and health
is behavior, or human acts. Nurses must Satisfaction will occur
have the knowledge and skill to observe
and interpret behavior and intervene in If transactions are made in nurse –client
the behavioral realm to assist individuals interactions
and groups cope with health, illness and
crisis (King 1981) Growth and development will
o Human beings have three fundamental be enhanced
health needs:
1) The need for health information
that is usable at the time when If role expectations and role performance as
it is needed and can be used. perceived by nurse and client are congruent,
2) The need for care that seeks to
prevent illness, and
3) The need for care when human Transaction will occur
beings are unable to help
themselves. If role conflict is experienced by nurse or
client or both,

Stress in nurse-client interaction

will occur.

Propositions of King’s Theory If nurse with social knowledge and skill

communicate appropriate information to
From the theory of goal attainment King client,
developed predictive propositions, which
include:
Concepts Mutual goal setting and goal
 think
If perceptual interaction accuracy is present attainment will occurs
 feel
in nurse-client
1. Human interactions,
being/person: is social being who  choose
is rational and sentient.  set goals
Person has ability to:
 select means to achieve goals
 perceive  and to make decisions
 According to King, human being has nurse and client share information about
three fundamentals needs: their perception in nursing situation”, and
“a process of human interactions between
 The need for the health nurse and client whereby each perceives
information that is available at the
the other and the situation, and through
time when it is needed and can be
communication, they set goals, explore
used.
means, and agree on means to achieve
 the need for care that seek to
prevent illness, and goals.”
 The need for care when human  Action: is defined as a sequence
beings are unable to help of behaviors involving mental and
themselves. physical actions.
2. Environment  Reaction: not specified, but might
Environment is the background for human be considered as included in the
interactions. It involves: sequence of behaviors described
in action.
 (a) Internal Environment:
transforms energy to enable  In addition, King discussed:
person to adjust to continuous  Goal
external environmental changes.  Domain and
 Functions and
 (b) External Environment:
professional nurse
involves formal and informal
organizations. The nurse is part of  Goal of nurse: “to help
the patient’s environment. individuals to maintain their
3. Health health so they can function in
their roles.
 According to King, health
involves dynamic life experiences  Domain of Nurse: “includes
of a human being, which implies promoting, maintaining, and
continuous adjustment to restoring health, and caring for
stressors in the internal and the sick, injured and dying.”
external environment through  Function of professional nurse.
optimum use of one’s resources “To interpret information in
to achieve maximum potential for nursing process to plan,
daily living. implement and evaluate nursing
care. King said on her theory, “A
professional nurse, with special
knowledge and skills, and a client
in need of nursing, with
knowledge of self and perception
of personal problems, meet as
strangers in natural environment.
They interact mutually, identify
problems, establish and achieve
4. Nursing goals.
Nursing is defined as “A process of
action, reaction and interaction by which
 Relationship to Nursing Processes

Nursing Process and Theory of Goal Attainment

Nursing Process Method Goal Attainment Theory
A system of oriented actions A system of oriented concepts
Assessment Perception, communication, and interaction of
nurse and client
Planning Decision making about the goals
Agree on the means to attain the goals
Implementation Transaction made
Evaluation Goal attained

Overall Assumption of King’s Conceptual System are as follows:

1. Perceptions, goals, needs, and values of the nurses and clients influence interaction
processes.
2. Individuals have the right to knowledge about themselves and to participate in decisions
that influence their lives, health, and community services.
3. Health professionals have the responsibility that helps individuals to make informed
decisios about their health care.
4. Individuals have the right to accept or reject health care
5. Goals of health professionals and recipients of health care may not be congruent.
 King’s Conceptual A. Personal System
Framework 8. Coping
Includes three interacting 1. Perception
systems namely: “A process of organizing, interpreting, and transforming
information from sense data and memory” (King, 1981)
A. Personal System 2. Self
System “The self is a composite of thoughts and feelings which constitute
B. Interpersonal System
a person’s awareness of his/her individual existence, his/her
C. Social System conception of who and what he/she is. A person’s self is the sum
total of all he/she can call his/hers. The self includes, among other
things, a system of ideas, attitudes, values and commitments. The
self is a person’s total subjective environment. It is a distinctive
center of experience and significance. The self-constitutes a
Individual are personal systems (King, person’s inner world as distinguished from the outer world
1981). Each individual is an open, consisting of all other people and things. The self is the individual
total, unique system in constant as known to the individual. It is that to which we refer when we say
interaction with the environment. “I”” (Jersild, 1952)
3. Growth and Development
“The processes that take place in an individual’s life that help the
individual move from potential capacity for achievement to self-
actualization. “ (King, 1981)
The following concepts provide 4. Body Image
foundational knowledge that “An individual’s perception s of his/her own body, other‘s
contributes to understanding reaction to his/her appearance which results from other’s reactions
individuals as personal systems:
to self” (King 1981)
Learning
“A process of nursing perception, conceptualization , and critical
1. Perception thinking involving multiple experiences in which changes in
concepts, skills, symbols, habits , and values can be evaluated in
observable behaviors and inferred from behavioral manifestation”
2. Self
(King 1986)
5. Time
3. Growth and 6. “Duration between the occurrence of one event and
Development occurrence of another event” (King 1981)
7. Personal Space
“Existing in all directions and is the same everywhere.” (King
4. Body image 1981)
8. Coping
“The constantly changing cognitive and behavioral efforts to
5. Space manage specific external and internal demands that are appraised as
taxing or exceeding the resources (Lazarus and Folkman, 1984)
This definition seemed very consistent with King’s view of stress
6. Time and individuals.

7. Personal Space
 King’s Conceptual
Framework
Includes three interacting B. Interpersonal System
systems namely:

A. Personal System 1. Communication

System “Information Processing, a change of information from one state
B. Interpersonal System
to another” (King, 1981)
C. Social System 2. Interaction
“Acts of two or more persons in mutual presence” (King 1981)
3. Role2. Interaction
Two or more individuals in interaction “Set of behaviors expected when occupying a position in a social
form interpersonal systems (King system” (King 1981)
3. Role
1981). As the member of individuals
increases, so does the complexity of the 4. Stress
interaction. King’s Process of nursing “Dynamic state4.whereby
Stress a human being interacts with the
occurs primarily within the environment to maintain balance for growth, development, and
interpersonal systems between the nurse performance which involves an exchange of energy and
and patient. 5. Stressors
information between the person and the environment for
regulation and control of stressors. “(King 1981)
6. Transaction
5. Stressors
Concepts Critical to understanding “Events that produces stress.” (King 1981)
interactions between individuals are as
follows: 6. Transaction
“Observable behaviors of human beings interacting with their
environment” (King1981)

1. Communication

King’s Conceptual
Framework
Includes three interacting
systems namely: A social system is “an organized
boundary system of social role,
A. Personal System behaviors and practices developed to
System maintain values and the mechanisms
B. Interpersonal System
to regulate the practice and rules
C. Social System (King 1981).
Example of social systems include
health care settings, workplaces,
Social systems are composed of large educational institutions, religious
groups with common interests or goals organizations and families.” (King
1981)
Interactions with social systems influence
individuals throughout the lifespan.
1. Organization

Concepts that are useful to understand

interactions within social systems and 3. Power
2. Authority
between social and personal systems are
as follows: 4. Status

5. Decision making

C. Social System Theory of Goal Attainment

Basic assumption of goal attainment theory is that
nurse and client communicate information, set
1. Organization goal mutually and then act to attain those goals.
“A system whose continuous activities are conductedThis is also the basic assumption of nursing
to achieve
goals” (King 1981) processes.

2. Authority
“Transactional process characterized by active, reciprocal
relations in which members’ values backgrounds, and
perceptions play a role in defining, validating, and accepting the
directions of individuals within an organization” (King 1981) Assessment
3. Power
“The capacity or ability of a group to achieve goals.” (King
1981) Nursing diagnoses

4. Status
“The position of an individual in a group or a group in relation Planning
to other groups in an organization” (King 1981)
5. Decision Making
“Dynamic and systematic process by which a goal-directed Implementation
choice of perceived alternatives is made, and acted upon, by
individuals or groups to answer a question and attain a goal”
(King 1981)
Evaluation
 Assessment In goal attainment, planning is
King indicates that represented by setting goals and making
assessment occur during decisions about and being agreed on the
interaction. The nurse means to achieve goals.
brings special knowledge This part of transaction and client’s
and skills whereas client participation is encouraged in making
brings knowledge of self decisions on the means to achieve goals.
and perception of problems
of concern, to this  Implementation
interaction. In nursing process implementation
involves the actual activities to achieve goals.
During assessment In goal attainment it is the
nurse collects data continuation of transaction.
regarding client
 Evaluation
Perception is the
It involves the finding out whether
base for collection and
goals are achieved or not.
interpretation of data.
In King’s description, evaluation
Communication is
speaks about attainment of goal and
required to verify accuracy
effectiveness of nursing care.
of perception, for
interaction and transaction.
 Nursing Diagnosis
The data collected
by assessment are used to
make nursing diagnosis in
nursing processes.
According to King, in
process of attaining goal the
nurse identifies the
problems, concerns and
disturbances about which
person seeks help.
 Planning
After diagnosis,
planning for interventions
to solve those problem is
done.

Application of Imogene King’s Conceptual System and Goal Attainment Theory

Case History of Baby Michael
Baby Michael was born on June2, 2010, at 38 weeks’ age of gestation (AOG) by an
emergency cesarean section because of signs of fetal distress (fetal heart rate was very low) and
 premature rupture of membrane (PROM). This was his mother’s second pregnancy. She had
regular prenatal care and both pregnancies were uneventful.
Baby Michaels’s mother is 36 years old and his father is 38 years old. Their first child,
Joshua is 12-year old who is diagnosed to have autism. He requires constant care and is in a
special program during daytime hours.
At birth, Baby Michael weighed 7 lbs. and 5 ounces, had Agpar score of 8 and 9. This
indicated that he was in good condition. However, he developed respiratory distress several hours
after birth. He was transferred to neonatal ICU (NICU) and placed on ventilator. After few days,
he developed sepsis and seizures. Both parents visited daily and participated in his care.
The family including the paternal and maternal grandparents talked to the physicians
about Baby Michael’s chance for survival, the quality of his life if he survives, and any pain or
discomfort hew might be experiencing at the time. His condition deteriorated further and he had
also developed renal failure. He was not expected to survive more than few days. The family
asked for a priest to visit to perform an emergency baptism.
In spite of such critical condition, Baby Michael showed signs of improvement over the
next few days although he remained on a ventilator. One week later, he was tolerating nasogastric
tube feeding. Breathing continued to improve and he was eventually removed from the ventilator.
His condition stabilized and he began to make steady progress. The family is looking forward that
Baby Michael will soon be discharged as his physiological problems are resolving.

Nursing Care of Baby Michael with

Imogene King’s Conceptual System and Theory of Goal Attainment
Nurse Aubrey Anne Bermudez was assigned to care for Baby Michael from the time he was
admitted in the NICU. The first step in the process is conceptualization and assessment that uses each
of the concepts identified within each system. Nurse Aubrey Anne begins to think about Baby Michael
and his family in terms of three interrelated systems: the personal, interpersonal, and social.
In Baby Michael’s case, Nurse Aubrey Anne identifies four individual or personal
systems: Baby Michael, his mother, his father, and Nurse Aubrey Anne.
Interpersonal systems are formed when 2 or more personal systems interact- Baby
Michael with mother, father, Nurse Aubrey Anne; Nurse Aubrey Anne with the mother, and
father, etc. There is presence of multiple interpersonal systems.
Social systems are larger groups that influence the personal and interpersonal systems.
Nurse Aubrey Anne takes note of Baby Michael’s extended family, particularly his grandparents.
Religious systems could also play a role in this case because Baby Michael’s survival is
uncertain. The NICU is also a social system with its own inherent and often overwhelming power
and authority, values, patterns of behavior, and role expectations.
One value that is strongly supported in this NICU is the philosophy of family-centered
health care, which recognizes and respects the role of families in the care of their children. King’s
conceptual system supports the principles of family-centered care in the NICU. Interactions,
 transactions, and mutual goal setting can be implemented with Baby Michael’s parents to
promote the health of the family system by assisting them to function in their roles as parents.
The next step that Nurse Aubrey Anne takes is to gather data and apply knowledge
of the concepts identified within the personal system:
(1) Perception, (2) self, (3) growth and development, (4) body image, (5) time and (6)
personal space. Nurse Aubrey Anne decides that the most important concept to apply to Baby
Michael as a newborn is growth and development.
Nurse Aubrey Anne recognizes that Baby Michael’s illness and its treatment will have
the following effects:
a. Interference with normal newborn behavior, which could impede parental interaction and,
possibility attachment.
b. Inability to meet development milestones, either on time or at all.
c. Intensification of sense of chronic sorrow that accomplishes the “loss” of a perfect, healthy
infant in Baby Michael’s parents because of their experience with their first-born child.
Nurse Aubrey Anne’s first step is to assess perceptions of his health status and the
situation. She let Baby Michael’s parents to express their emotional tensions and grief.
Afterwards, they both expressed deep concern for Baby Michael’s survival and for any long-term
health implications. Nurse Aubrey Anne perceived that they were exhibiting a normal,
appropriate reaction to the present situation.
Another important concept is self. Baby Michael’s parents bring a unique self to this experience
that defines them as individuals. They already had established themselves as mother and father with their
firstborn. Nurse Aubrey Anne also considers that they may be experiencing guilt and anger because they
repeatedly question why they could not have a normal child.
The concept of personal space is relevant in the case of Baby Michael and his parents. Since the
NICU have no personal, private space where Baby Michael’s parents can express themselves and interact
with him, there is no privacy at all.
Time is another concept within the personal system that affects Baby Michael’s parents. The
uncertainty surrounding Baby Michael’s medical status requires continual adjustment in terms of time.
When Baby Michael was finally taken off from the life support machines, his parents expected that in
time he would be ready to go home. Unfortunately, this time sequence was disrupted by other life-
threatening crises.
Growth and development is also a relevant concept for Baby Michael’s parents. The addition of
another family members signals a development challenge. Baby Michael’s parents will continue to grow
and develop as parents.
Pertinent concepts in the interpersonal system that Nurse Aubrey Anne considers include
interaction, communication, transaction, role and stressors/stress. She communicates with the parents
throughout Baby Michael’s hospitalization and provides them with the information they need to function
in their parental role. Such communication establishes mutuality and trust between the parents and Nurse
Aubrey Anne, which in turn leads to interactions and ultimately transactions. One characteristic of
interaction is reciprocity, interdependence in the relationship in which there is an exchange between the
persons involved.
 The NICU itself is a noisy, bustling tension-filled environment. All kinds of alarms and buzzers
send out signals of potential danger, which heighten concerns for Baby Michael’s parents. They often
comment on unexpected and unplanned stress on their day to day lives. They must continue to provide for
their older soon; they feel compelled to visit Baby Michael every day; they must drive back and forth to
the hospital; they must maintain the normal routines of doing laundry, shopping for groceries, and going
to work.
Role is another important concept in the interpersonal system. Nurse Aubrey Anne knows that
parents often feel inadequate compared with the nurse who cares for their infant. An alteration in the
parenting role may interfere with the ability of Baby Michael’s parents to engage in mutual goal setting
that leads to transactions (Norris and Hoyer, 1993). Nurse Aubrey Anne brings a strong commitment to
family-centered care to her nursing practice. Initially, she defines the goal of helping the parents establish
their parental role and also plans to redefine that goal with them when they are ready.
The concepts of authority, power, status, and decision making are characteristics of social
systems that are relevant in Baby Michael’s case. Nurse Aubrey Anne knows that for most parents the
NICU represents a highly technological threatening situation unlike any other social situation they have
experienced. As a social system, the NICU possess authority and power that appear to exceed that of the
parents. Parents often perceive that they have little status. Physicians and nurses have expertise and skills
with which parents cannot compete in caring for their child. Unless the NICU supports a philosophy of
family-centered care, parents may not be actively involved in care or care decisions.
At one point, Nurse Aubrey Anne observed that baby’s Michael’s mother had a tendency to focus
on the details of the technological care. Nurse Aubrey Anne interpreted this that the mother might be
experiencing powerlessness in the present situation. In addition, the nurse perceived that a loss of control
may threaten the self. The mother may feel threatened and therefore make issues out of little things. The
nurse took an opportunity to discuss her perceptions with the mother, who validated that she did not feel
like a mother and claimed that she could do nothing for her child as his mother because the nurses did
everything.
Taken together, the concepts of interaction, perception, communication, transaction, self, role,
stressors/stress, growth and development, time, and personal space constitute the Theory of goal
attainment. Through communication and interaction, the parents and the nurse clarified their perceptions
of the situation and mutually established the goal of identifying aspects of care that they could provide
within the constraints of Baby Michael’s physical status, treatment, and the NICU environment. The
nurse’s role was to teach and assist them to care for the child safely and to maximize opportunities for the
parents to provide comfort measures. Within several days, the nurse observed the mother was
independently initiating aspects of care and was becoming skillful at performing them even within the
confines of the NICU. As her level of confidence increased, the mother become less focused on minor
changes in technological aspects of care such as levels of blood gas, ventilator settings, and began to
function in her role as parent. The mother demonstrated growth and development in behavioral activities
related to parenting in the environment and social system of the NICU. The nurse observed that verbal
and nonverbal manifestations of stress decreased for both parents.
The process of goal attainment occurs within the context of time with one event leading to
another. Discussion and validation of perceptions lead to judgment, action, and reaction for both parents
and the nurse. These actions were followed by the establishment of mutual goals during the process of
interaction, which led to the achievement of goals. Achievement of goals is transaction. Transactions lead
to improved health—in this case, the ability to be parents to their infant.
 Overtime, Baby Michael’s condition continues to improve to the point at which survival has very
great chance, but the need for special care when he goes home remains high. This represents a critical
time for parental participation in setting goals and developing plans to meet those goals so they are
prepared to assume full-time parenting roles and to incorporate any special care needs into their into their
daily routines. For example, an infant who had been on nasogastric tube feeding may be slow to establish
breastfeeding or bottle feeding. The nurse will communicate this information to the parents (1) to
decrease potential stress caused by unrealistic expectations and (2) to coordinate a consultation with
occupational therapy to teach the parents feeding strategies that will promote adequate weight gain and
growth.
The challenge to nurses working in any health care setting including special areas like NICU is to
look beyond the technological care they provide to the importance of interaction and transaction all
throughout the nurse-patient, nurse-family relationship. Patients and families expect competent ad
appropriate technological care. In addition, they need a caring relationship with nurses.
On the whole, King’s Conceptual System, Theory of Goal attainment and Model of transaction
provide direction for nursing practice because it emphasizes the processes of communication, interaction
and transactions, which are the foundations for promoting and maintaining the health status of individuals
and families. (Norris and Hoyer, 1993) The relationship that nurses establish with parents based on
mutual respect and trust also attain the goal of nursing, which is “to help individuals to maintain their
health so that they can function in their roles” (King 1981)
In summary, Imogene King has formulated a Conceptual System from which she derived a
Theory of Goal Attainment. The conceptual system consists of three systems- personal. Interpersonal,
and social--- all of which are in continuous exchange with their environments. The concepts of the
personal systems are perception, self, body image, growth and development, time, and space. The
concepts of the interpersonal systems are role, interaction, communication, transaction, and stress.
Social systems concepts are organization, power, authority, status, decision-making, control, and
role.
From these systems and their abstract concepts of human beings, health, environment and
society, King postulated a “Theory of Goal Attainment”. The major concepts of the Theory of
Goal Attainment are interaction, perception, communication, transaction, role, stress, and
growth and development. Each of these is defined, and overall propositions and criteria for
determining internal and external boundaries of the theory are presented.
Imogene King has developed a Theory of Goal Attainment that is based on a philosophy
of human beings and a conceptual system. She proposed a goal-oriented nursing record to
document, and a Goal Attainment Scale to measure goal attainment as results of her research.
The theory is useful, testable, and applicable to nursing practice. It is widely
generalizable and relevant in different health care situations.
Application of Imogene King’s Conceptual System and Goal Attainment Theory
Case History of Baby Michael
Baby Michael was born on June2, 2010, at 38 weeks’ age of gestation (AOG) by an
emergency cesarean section because of signs of fetal distress (fetal heart rate was very low) and
premature rupture of membrane (PROM). This was his mother’s second pregnancy. She had
regular prenatal care and both pregnancies were uneventful.
 Baby Michaels’s mother is 36 years old and his father is 38 years old. Their first child,
Joshua is 12-year old who is diagnosed to have autism. He requires constant care and is in a
special program during daytime hours.
At birth, Baby Michael weighed 7 lbs. and 5 ounces, had Agpar score of 8 and 9. This
indicated that he was in good condition. However, he developed respiratory distress several hours
after birth. He was transferred to neonatal ICU (NICU) and placed on ventilator. After few days,
he developed sepsis and seizures. Both parents visited daily and participated in his care.
The family including the paternal and maternal grandparents talked to the physicians
about Baby Michael’s chance for survival, the quality of his life if he survives, and any pain or
discomfort hew might be experiencing at the time. His condition deteriorated further and he had
also developed renal failure. He was not expected to survive more than few days. The family
asked for a priest to visit to perform an emergency baptism.
In spite of such critical condition, Baby Michael showed signs of improvement over the
next few days although he remained on a ventilator. One week later, he was tolerating nasogastric
tube feeding. Breathing continued to improve and he was eventually removed from the ventilator.
His condition stabilized and he began to make steady progress. The family is looking forward that
Baby Michael will soon be discharged as his physiological problems are resolving.

Nursing Care of Baby Michael with Imogene King’s Conceptual System and Theory of Goal
Attainment
Nurse Aubrey Anne Bermudez was assigned to care for Baby Michael from the time he was
admitted in the NICU. The first step in the process is conceptualization and assessment that uses each
of the concepts identified within each system. Nurse Aubrey Anne begins to think about Baby Michael
and his family in terms of three interrelated systems: the personal, interpersonal, and social.
In Baby Michael’s case, Nurse Aubrey Anne identifies four individual or personal
systems: Baby Michael, his mother, his father, and Nurse Aubrey Anne.
Interpersonal systems are formed when 2 or more personal systems interact- Baby
Michael with mother, father, Nurse Aubrey Anne; Nurse Aubrey Anne with the mother, and
father, etc. There is presence of multiple interpersonal systems.
Social systems are larger groups that influence the personal and interpersonal systems.
Nurse Aubrey Anne takes note of Baby Michael’s extended family, particularly his grandparents.
Religious systems could also play a role in this case because Baby Michael’s survival is
uncertain. The NICU is also a social system with its own inherent and often overwhelming power
and authority, values, patterns of behavior, and role expectations.
One value that is strongly supported in this NICU is the philosophy of family-centered
health care, which recognizes and respects the role of families in the care of their children. King’s
conceptual system supports the principles of family-centered care in the NICU. Interactions,
transactions, and mutual goal setting can be implemented with Baby Michael’s parents to
promote the health of the family system by assisting them to function in their roles as parents.
The next step that Nurse Aubrey Anne takes is to gather data and apply knowledge
of the concepts identified within the personal system:
 (1) Perception, (2) self, (3) growth and development, (4) body image, (5) time and (6)
personal space. Nurse Aubrey Anne decides that the most important concept to apply to Baby
Michael as a newborn is growth and development.
Nurse Aubrey Anne recognizes that Baby Michael’s illness and its treatment will have
the following effects:
d. Interference with normal newborn behavior, which could impede parental interaction and,
possibility attachment.
e. Inability to meet development milestones, either on time or at all.
f. Intensification of sense of chronic sorrow that accomplishes the “loss” of a perfect, healthy
infant in Baby Michael’s parents because of their experience with their first-born child.
Nurse Aubrey Anne’s first step is to assess perceptions of his health status and the
situation. She let Baby Michael’s parents to express their emotional tensions and grief.
Afterwards, they both expressed deep concern for Baby Michael’s survival and for any long-term
health implications. Nurse Aubrey Anne perceived that they were exhibiting a normal,
appropriate reaction to the present situation.
Another important concept is self. Baby Michael’s parents bring a unique self to this experience
that defines them as individuals. They already had established themselves as mother and father with their
firstborn. Nurse Aubrey Anne also considers that they may be experiencing guilt and anger because they
repeatedly question why they could not have a normal child.
The concept of personal space is relevant in the case of Baby Michael and his parents. Since the
NICU have no personal, private space where Baby Michael’s parents can express themselves and interact
with him, there is no privacy at all.
Time is another concept within the personal system that affects Baby Michael’s parents. The
uncertainty surrounding Baby Michael’s medical status requires continual adjustment in terms of time.
When Baby Michael was finally taken off from the life support machines, his parents expected that in
time he would be ready to go home. Unfortunately, this time sequence was disrupted by other life-
threatening crises.
Growth and development is also a relevant concept for Baby Michael’s parents. The addition of
another family members signals a development challenge. Baby Michael’s parents will continue to grow
and develop as parents.
Pertinent concepts in the interpersonal system that Nurse Aubrey Anne considers include
interaction, communication, transaction, role and stressors/stress. She communicates with the parents
throughout Baby Michael’s hospitalization and provides them with the information they need to function
in their parental role. Such communication establishes mutuality and trust between the parents and Nurse
Aubrey Anne, which in turn leads to interactions and ultimately transactions. One characteristic of
interaction is reciprocity, interdependence in the relationship in which there is an exchange between the
persons involved.
The NICU itself is a noisy, bustling tension-filled environment. All kinds of alarms and buzzers
send out signals of potential danger, which heighten concerns for Baby Michael’s parents. They often
comment on unexpected and unplanned stress on their day to day lives. They must continue to provide for
their older soon; they feel compelled to visit Baby Michael every day; they must drive back and forth to
the hospital; they must maintain the normal routines of doing laundry, shopping for groceries, and going
to work.
 Role is another important concept in the interpersonal system. Nurse Aubrey Anne knows that
parents often feel inadequate compared with the nurse who cares for their infant. An alteration in the
parenting role may interfere with the ability of Baby Michael’s parents to engage in mutual goal setting
that leads to transactions (Norris and Hoyer, 1993). Nurse Aubrey Anne brings a strong commitment to
family-centered care to her nursing practice. Initially, she defines the goal of helping the parents establish
their parental role and also plans to redefine that goal with them when they are ready.

The concepts of authority, power, status, and decision making are characteristics of social
systems that are relevant in Baby Michael’s case. Nurse Aubrey Anne knows that for most parents the
NICU represents a highly technological threatening situation unlike any other social situation they have
experienced. As a social system, the NICU possess authority and power that appear to exceed that of the
parents. Parents often perceive that they have little status. Physicians and nurses have expertise and skills
with which parents cannot compete in caring for their child. Unless the NICU supports a philosophy of
family-centered care, parents may not be actively involved in care or care decisions.
At one point, Nurse Aubrey Anne observed that baby’s Michael’s mother had a tendency to focus
on the details of the technological care. Nurse Aubrey Anne interpreted this that the mother might be
experiencing powerlessness in the present situation. In addition, the nurse perceived that a loss of control
may threaten the self. The mother may feel threatened and therefore make issues out of little things. The
nurse took an opportunity to discuss her perceptions with the mother, who validated that she did not feel
like a mother and claimed that she could do nothing for her child as his mother because the nurses did
everything.
Taken together, the concepts of interaction, perception, communication, transaction, self, role,
stressors/stress, growth and development, time, and personal space constitute the Theory of goal
attainment. Through communication and interaction, the parents and the nurse clarified their perceptions
of the situation and mutually established the goal of identifying aspects of care that they could provide
within the constraints of Baby Michael’s physical status, treatment, and the NICU environment. The
nurse’s role was to teach and assist them to care for the child safely and to maximize opportunities for the
parents to provide comfort measures. Within several days, the nurse observed the mother was
independently initiating aspects of care and was becoming skillful at performing them even within the
confines of the NICU. As her level of confidence increased, the mother become less focused on minor
changes in technological aspects of care such as levels of blood gas, ventilator settings, and began to
function in her role as parent. The mother demonstrated growth and development in behavioral activities
related to parenting in the environment and social system of the NICU. The nurse observed that verbal
and nonverbal manifestations of stress decreased for both parents.
The process of goal attainment occurs within the context of time with one event leading to
another. Discussion and validation of perceptions lead to judgment, action, and reaction for both parents
and the nurse. These actions were followed by the establishment of mutual goals during the process of
interaction, which led to the achievement of goals. Achievement of goals is transaction. Transactions lead
to improved health—in this case, the ability to be parents to their infant.
Overtime, Baby Michael’s condition continues to improve to the point at which survival has very
great chance, but the need for special care when he goes home remains high. This represents a critical
time for parental participation in setting goals and developing plans to meet those goals so they are
prepared to assume full-time parenting roles and to incorporate any special care needs into their into their
daily routines. For example, an infant who had been on nasogastric tube feeding may be slow to establish
breastfeeding or bottle feeding. The nurse will communicate this information to the parents (1) to
decrease potential stress caused by unrealistic expectations and (2) to coordinate a consultation with
occupational therapy to teach the parents feeding strategies that will promote adequate weight gain and
growth.
The challenge to nurses working in any health care setting including special areas like NICU is to
look beyond the technological care they provide to the importance of interaction and transaction all
throughout the nurse-patient, nurse-family relationship. Patients and families expect competent ad
appropriate technological care. In addition, they need a caring relationship with nurses.
On the whole, King’s Conceptual System, Theory of Goal attainment and Model of transaction
provide direction for nursing practice because it emphasizes the processes of communication, interaction
and transactions, which are the foundations for promoting and maintaining the health status of individuals
and families. (Norris and Hoyer, 1993) The relationship that nurses establish with parents based on
mutual respect and trust also attain the goal of nursing, which is “to help individuals to maintain their
health so that they can function in their roles” (King 1981)
In summary, Imogene King has formulated a Conceptual System from which she derived a
Theory of Goal Attainment. The conceptual system consists of three systems- personal. Interpersonal,
and social--- all of which are in continuous exchange with their environments. The concepts of the
personal systems are perception, self, body image, growth and development, time, and space. The
concepts of the interpersonal systems are role, interaction, communication, transaction, and stress.
Social systems concepts are organization, power, authority, status, decision-making, control, and
role.
From these systems and their abstract concepts of human beings, health, environment and
society, King postulated a “Theory of Goal Attainment”. The major concepts of the Theory of
Goal Attainment are interaction, perception, communication, transaction, role, stress, and
growth and development. Each of these is defined, and overall propositions and criteria for
determining internal and external boundaries of the theory are presented.
Imogene King has developed a Theory of Goal Attainment that is based on a philosophy
of human beings and a conceptual system. She proposed a goal-oriented nursing record to
document, and a Goal Attainment Scale to measure goal attainment as results of her research.
The theory is useful, testable, and applicable to nursing practice. It is widely
generalizable and relevant in different health care situations.