...meet the advocates of Goal Attainment Theory...
Goal Attainment Theory in Medical-Surgical ward by April
Nurses are the front-liners of patient care. We are provided with various opportunities in interacting with our patients, e.g. during their hospitalization period. It is thus wise for us nurses to be knowledgeable in theories which can aid in fruitful nurse-patient relationship. Imogene King’s Goal attainment theory is one of those that continuously guide our understanding in different nurse-patient interactions which are beneficial in the attainment of client’s goal.
As a nurse who has worked in the medical surgical ward, I have been given this precious opportunity to interact with patients coming from all walks of life. An effective communication which have been emphasised by King is very much valued during the interaction process. It is not just important that my patients and I spoke of the same language, what matter most is on how we look the situation in the same perspective. With this I mean that the nurse should not have a wrong notion that existing in the same place, time and situation guarantee congruent perception of the nurse and patient to the situation.
I have this experience with a post op patient who has undergone cholecystectomy surgery. The first thing that I did was to verify if we have a reciprocal perception to his situation. I ask questions that usually lead to the determination if the patient realizes the risks that his condition poses, how he looks at himself as a post op patient etc. After which, we identified a problem like his lack of interest in ambulation and post op exercises. I as a nurse taught him the implication of his actions, as well as the complications that may arise from those. We then set a goal which is for him to remain free from post op complications. Next we agreed on the ways that we both selected, and I as a nurse assisted him in performing the appropriate actions (e.g. ambulation, deep breathing exercises, adequate intake of food and water to provide adequate nutrition.). After a 4 day care, the patient was discharged free from complications.
This is how Imogene King’s Goal Attainment theory plays a role in my journey as a nurse.
Advance Cardiac Life Support and Goal Attainment Theory by Armie
Two days ago, I attended a class to renew my ACLS license which is mandatory in our ER hospital setting. While we were doing the megacode, I realized that Imogene Kings Goal Attainment Theory can be applied in any setting and as simple as ACLS.
The common goal attainment is to save the life of the patient who had a cardiac arrest by using a highly effective and efficient resuscitation by having “ reciprocal relationship and a shared perception of the situation”. Interactions starts as soon as the nurse ask the client if he needs help and when the nurse calls for help. The nurse assumes the role of a giver by providing a highly effective chest compressions and proper breathing. As soon as help arrives, each resuscitating members must take significant roles in which they are proficiently skilled like knowledge of electrocardiogram tracings, the right dose and right medications, or knowledge of the algorithms of each tracings. The person who assumes the role as a team leader has the authority to guide the megacode, by giving messages, orders, or assignments to each team members. When the resuscitation efforts seems to be ineffective, the team leader and team members communicate with each other for inputs by going over the algorithms and search for what was missed . The decision is then made when the goal –directed choice of perceived alternatives is acted upon by the group in order to achieve a goal which is to save the patient’s life.
References:
American Heart Association Advance Cardiovascular Life Support: Professional
Theoretical Foundations of Nursing - Anonuevo, Abaquin, Balabagno, Corcega, Dones, Kuan, Laurente, Mejico, Tuazon , UPOU
Goal Attainment in the Critical Care Department by Arvie
I worked in the Critical Care Department nurse for three years, and in my more than five years of being a nurse, I have come to like Imogene King’s Theory Of Goal Attainment because it is applicable to most practice areas including those in which the patient is incapable of interacting with his environment due to some sort of disability or mental impairment. My own experience in Saudi as an ICU nurse have proven countless of times how families can be incorporated into application of the Theory when patients are comatose. As long as the family is attempting to act in the best interest of the patient, the theory of Goal Attainment may still be utilized. In addition, the concept of nursing depicts the importance of nurses in the care of patient wherein focus is still upon the attainment of patient’s health through goals set collaboratively by both the patient and nurse. I also like the inclusion of effective communication and interaction of nurses and patients in planning for the care to be rendered. This just proves that nurses are important and patients are more important in establishing health.
Goal attainment is explained as a general method to evaluate the outcome of a health treatment to a client. (Cardillo, J. and Kiresuk, T. Goal Attainment Scale, 2010). Goal attainment appeared to be generally applicable to many forms of service industry. It is developed at a time of great demand for evaluation and since that time there have been many applications of Goal Attainment in the fields of nursing, education and program administration.
Going through with my experience in Palliative, Hospice and Supportive Care nursing, I always take into consideration to enlist all activities each day for our patient, for each staff member and for the organization. Trying to respectively perform the details of each program every single day and see to it that things had been set and planned are attained.
At the end of the day, upon review of the set goals (short term), we assess if we are able to help the patient and his family, we check if the nursing staff met their planned activities and if we have contributed our share of expertise to the institution.
I remember one cancer patient (now expired) who was then in the care of our hospice and palliative unit. We regularly visit her twice a week for home care. From the time she referred to our clinical team by Boston Hospital, USA until the palliation phase of treatment she needed, a planned program of care and treatment for her was presented to her and her family. Advanced directives were carefully explained. Final transitions were presented. Intervention and implementation was observed and done. Our evaluation, effectiveness of nursing care, indeed a ‘goal attainment.’
Every encounter with this patient is an application of King’s Goal Attainment Theory because nursing process is being carefully utilized and outcome of the care plan with the whole clinical team with the participation of the patient (and her family) plus the support of the management institution are all appropriately and effectively achieved.
Theory supports the practice when King stated that, “efficient nursing care will happen, if goals are met.” The existing evidences in every complex area of nursing practice are supported by King’s careful researches and studies, which had been unlimited to the use of nursing diagnosis and nursing care plan.
Interpersonal process, interaction and transaction are goal-directed. And these provide a frame of reference toward goal setting.
References
1. Cardillo, J. and Kiresuk, T. (2010). Goal Attainment Scale, pp 1-2.
2. Ocampo-Balabagno, A. (2000). Theoretical Foundations of Nursing: Nurse-Client
Dynamics, pp. 137-143.
3. Octaviano, E. and Balita, C. (2008). Theoretical Foundations of Nursing. Imogene
King’s Goal Attainment Theory, pp 115-120.
4. Udan, J. (2011). Theoretical Foundations of Nursing, pp. 88-89.
5. Sitzman, K. and Eichelberger, L. (2011). Understanding the Work of Nurse Theorists:
A Creative Beginning , p. 163.
Having the opportunity to study Imogene Kings Goal Attainment Theory geared me to know the principle of quality of patient care. Being a Critical Care Nurse, we are confronted with extreme cases with higher expectancy thus dealing with critically ill patient entails life and also death. Our goal is to save and further improve the quality of life those of critically ill patient. But at times it is difficulty arises in communication but still goals can be met. I used to talk and utter phrases with my patients like Lalabana natin ang sakit mo, tulungan mo akong tulungan ka..dapat makakalabas ka dito sa ICU ng malakas …Dapat ma-wean ka sa mechanical ventilator mo. King has responded deliberately in this issue hence, noting that 70%of communication is non-verbal .So the need in nursing is to broaden nurses’ knowledge in communication and this is what her theory is telling us about.
Imogene King contributed to the advancement of nursing knowledge through the development of her conceptual system and middle range Theory of Goal Attainment. By converging on the attainment goals, or outcomes, by nurse-patient partnerships, she delivered a conceptual system and middle range theory that has established its usefulness to nurses in the present and in the future. They will continue to use King’s work to improve quality of patient care.
I use King's theory in my work. However, most of the time, I use the theory not on the patient, but on the relatives or guardians of the patient (especially when the patient cannot decide for himself). In the ER, everything is fast-paced. We need to think fast and act fast. Sometimes, the relatives are having a difficult time in making decisions regarding their patients because of several factors (lack of money, family issues, deteriorating health, which will look after, etc.). Being the patient's advocate, I help the family on their decision by clearly presenting to them the situation. I then hear what they see and what they want to do with the patient. I then try to clear misconceptions or fill them up with information that they need to know. I present to them their options and the possible consequences of their actions. From there, we make decisions or we set up goals that we (me and the relatives) think is best for the patient.
We encounter a variety of patients everyday in our workplace. They are each unique with their needs, perceptions and ideas regarding their situations. Using Goal Attainment Theory, we try to understand them so we can have a good relationship with them. Patients and nurses communicate with each other to achieve goals. Once we have a good working relationship with our patients, we are able to intervene more effectively.
When a patient is admitted to the hospital, he is often very anxious and worried about what will happen during his stay in the hospital. As early as the time of admission, we try to create a relationship with him that will last while he is under our care. We talk to him and find out what his expectations are, what he knows about his problem and what he needs to do to get better. For example, I often encounter diabetic patients in my work. At first, I try to find out what she knows about diabetes and let her talk about her worries since this can be a barrier to effective care. We clear out misunderstandings and we find a mutual goal which is for her to gain better control of her sugar. We come to an agreement that we will do what we can to manage her disease so she can be healthier which include lifestyle changes and learning about the disease and its management. I reiterate what lifestyle changes she has to make to achieve her goal. For example, sometimes patients think that the only food they have to cut back on are chocolates or cakes. We correct these ideas. I teach her and her family how to take her blood sugar and how to inject insulin so she can continue the management after discharge. There must be cooperation between the healthcare staff and the patient for her care to be successful. No matter how many times we check her sugar and give insulin or medications, if the patient does not understand and does not cooperate with us then it will just be a cycle and she won’t be able to attain a good glycemic control.
In this theory, the client and nurse both determine the needs and set the goals as well as the way they will meet those goals. It is a mutual decision that both the nurse and patient make. When we give our clients a sense of independence and importance, when we consider their needs and plan with them their care, they are more likely to cooperate with us so we can achieve a mutually set goal.
I render care to patients with End- stage renal disease.
CAPD stands for Continuous Ambulatory Peritoneal Dialysis. Selected patients will do Capd and some Hemodialysis. For CAPD Tenckhoff catheter will be inserted surgically, after 5 days we will check the patency of the catheter by doing flushing. This is where our interaction with the patient starts.
When doing our first flushing, patient will complain of pain while we infuse and drain peritoneal dialysis fluid. Their initial reaction is not to move to lessen the pain. But, moving or shaking their abdomen is necessary for fluid to drain. A good communication will allow them to understand that it is part of the modality they chose. Explanation is very crucial for them to cooperate with us. We will explain that for the fluid to come out fully they have to move their abdomen and they have to bear the pain. We will assure them that after a couple of days the pain will disappear. Giving rest periods is important for them to adjust with the pain.
After first flushing and we see that the catheter is ready to be used. We will start to prepare them for training. We have two options actually. CAPD is a manual procedure it must be done 4 times a day every 6 hourly or APD (automated peritoneal dialysis) is a machine where the patient can do dialysis while asleep for 8 hours or more. It is the machine who will do exchanges of fluids. It is not applicable for all patients I should say.
A patient is train to do dialysis at home. Our goals are for them to be independent and be free of infection. Communication is a very effective tool to attain these goals. We address every concern they have. We fully explain the proper procedure of their modality to avoid infection.
Every now and then we make sure that our patient is being compliant not only with the dialysis itself but as well as the medication they have to take. We conduct monthly appointment in our Unit to take blood samples and refer the results with the treating doctors.
So far we have less cases of Peritonitis, and most of our patients are really compliant with their treatment. It is very rewarding if you know that they do actually follow the treatment course.
Another thing to feel them secured and very well taken cared of is that we let them know that we are available whenever new concern arises.
I’m assigned in Orthopedics ward here in the UAE. One, day we had an admission that is for spine surgery on the next day. When he came to our Ward, we oriented him in the room (nurse call bell, bed remote control, emergency pull button and etc.) We also coordinated with the Physiotherapist to come to show him what he body mechanic he need to do (rising from the bed, getting out of bed and etc.) we also called the pain team to explain what kind of pain to expect and how is he going to manage it after the surgery. All paper works done, all consent signed…patient is ready for the surgery
Next day, surgery was done and as the doctor discussed to the patient relatives that the procedure was successful. All the relatives went home to rest after hearing the good news. After he became stable from the PACU, they transfer him back to our ward. When patient woke up he called us and asks where his relative is. I told him that they went home so that they can rest as well.
After sometimes, he called again and this time he was asking for food. I told him that the food is on the table and prepared it so that he can eat. I ask him if he can manage to feed himself then he answered ‘YES”. When I was about to get out of the room he called me again and said “sister, I think I will not be able to feed myself, can you help me?” I went near to him and said “ok let me help you”… As I assist him, he started telling stories about his family and from the tone of his voice I can sense that he is anxious about the surgery. I ask him if there something bothering him and he reply “will I be able to walk again?” and I replied “do you have any concern about your surgery?” he told me he’s afraid that no one will help him because all of his relatives are busy and having a family of their own. He’s afraid that no one will assist him if the doctor will discharge him on the next day. I told him that he doesn’t have to be worried because the doctor said everything went good. Then I started to ask him…”can u try to feed yourself” so he tried to do it under my supervision… He was able to finish his food and he acknowledges my help and encouragement to feed himself.
On the third day, surgeon said that he can now ambulate at his own will provided that he will wear a lumbo-sacral corset. The physiotherapist came to ambulate him after I had put the corset. I was there when the PT started to assist him to get out of the bed. I saw mixed emotion of pain, anxiety then he express reluctance ..” sister, I think I cannot do it” I told him “you need to try…pain will always be there but you should try to help yourself so that if in case nobody will help you at home… you know how to do it by yourself” then with all his will and assistance on our part (PT and me), he is now standing. He tried to have a few steps inside his room and eventually they get out and had a one round of walking within our ward. After the Physiotherapy session, we put him back to bed.
He told me “sister, thank you for encouraging me to walk. I thought I will not be able to do it” and I replied to him “your maximum independence on how to take care of yourself, and seeing you walking out of this door is my greatest fulfillment for this day”. Then he smiled back and told me “may our good God bless you”
Then that day I went home feeling happy and fulfilled.
Quality management and nursing are like two entities being put together to make a one happy and satisfied client in the health care industry. Recent consciousness of how to improve quality in the service that we render to patients has created for new job opportunities just like my job today.
As a quality analyst working under the Quality Assurance Department, I measure the level of quality that we give to patients through the help of indicators that reflect the kind of service that medical workers offer to clients. I am also part of the Continuous Improvement Department assigned to create programs that facilitate breakthrough changes in making people coming to our institution better and healthy. In line with creating and implementing new programs, the Goal Attainment Theory of King creates a perfect opportunity of the importance of theories in our practice.
In the process of creating a program, the perception of every participant creates an effect in how the program will be. The perception is communicated in every interaction that we make with each other. King maintains that for a goal to be attained, the perception of each member of a problem to be addressed are accurate in that what they deem is important and is both known to all members as mentioned by George in 1995. For instance, a program in improving the turnaround time of laboratory personnel in processing requests for Complete Blood Count has to be known to all members of the committee making the study. A common perception of what seems to be the sources of delay should happen first before steps are to be taken in resolving them.
Each member’s perception paints a certain effect in the whole process of making the study. Through interaction wherein mutual understanding of what needs to be done is facilitated, achieving the goal is possible and can lead to transaction after a communicated accurate exploration of means and goal.
In the final step, transaction happens when we as a committee doing the study for turnaround time improvement implements improvement in the workflow of the laboratory personnel. For this reason, the theory of King guides us in how to achieve goals in that it does not forget that the importance of every individual’s perception and communication.
Reference
George, J. B. , (Ed). (1995). Nursing theories: A base for professional nursing practice. Connecticut: Appleton and Lange.
Imogene King’s Goal Attainment theory provides enough direction on how nurses should be able to behave or act in the presence of patients. Since majority of nursing activities involves direct interaction with the patients. This theory is applicable to most practice areas except for those in which the patient is incapable of interacting with his environment due to some sort of disability or mental impairment. However, patient’s families can be incorporated into application of the theory in those situations if it can be established that the family is attempting to act in the best interest of the patient.
A classic evident of implication of this theory is when I encountered patient that is difficult to work with and demanding with the attention. Upon entering in patient’s room, I asked him how he feels. Patient responded by complaining about a variety of concerns that could be considered minor by most nurses. Accepting that the patient’s perceptions are unique and valid to them, I spend few minutes just listening. The patient was about to discharge that day. So I asked him what he knows about his pending discharge and what his goals might be. He replied that he is concerned about leaving the hospital because he does not know what he can expect when he is already at home. I talked to him about his pending discharge and ask him to identify goals he wants to achieve for his condition. Patient identifies some goals to achieve and says that he would like to arrangement for someone to stay with him at his home, at least for a night.Of the goals identified, my patient and I prioritized the goals and identify activities that can be done by the patient and with his significant others to achieve his goals. Before I leave the patient we both agreed on the goals, priority and specific activities to maintain and improve his condition.
In this kind of situation the goal attainment theory of Imogene King is very essential. They are useful in promoting and maintaining health as well as preventing occurrence of disease that are the goals of nursing.
The Goal Attainment Theory emphasizes the importance of good communication and interaction between the nurse and the patient in order to set specific goals. In every health care setting, the concept of the theory is almost always applicable.
According to King, a shared perception of the situation is required for goal attainment and only then the interaction can be said to be effective. Having a shared perception can only be possible if there is proper communication between the nurse and the patient. By expression of his/her feelings about his/her condition, as nurses we easily and appropriately identify the problem which needs to be address and resolve.
As a nurse working in the surgical area, part of my responsibility is to deal with patient’s anxiety. By giving correct information and entertaining their doubts and questions about their condition can somehow lessen their anxiety and only then I can gain their full cooperation. I always keep in mind that my patient should always be involve in every aspect of his/her care in order for me to give appropriate and individualized quality nursing care.
As a nurse working in hemodialysis department of a hospital, we cater to both in patients and out patients Hemodialysis patients. I am able to apply Imogene King’s theory of goal attainment mostly on out patients whose major reason in coming to our hospital is to be hemodialyzed. Even if hemodialysis is their only reason for visit, as health care providers, it is still our responsibility to update their health condition as well as their coping abilities in relation to their health status.
As nurses, we are the health care providers who deal with the patients most of the time. We are the ones whom they can immediately interact to, regarding their health issues. Most of the time, I encountered HD patients who gain a lot of weight during the interval days of their HD schedules. All of them are aware of the alteration they have in terms of eliminating excess fluid from their body. But the problem lies within their fluid intake perception. Most of them are aware that their fluid intake is already limited to a certain number of liters or ml per day. But some of them do not understand that per day means 24 hours a day including coffee, soup etc. Most of them thought that fluid intake means water consumption. That’s why as nurses, it is our responsibility to explain to them thoroughly the things that they should do in order to maintain a compliant therapy. There are also some HD patients who thought that during hemodialysis, all of their fluid gain (regardless of how big it is), can be removed. Again, as a nurse, we have to explain to them the possible complications of removing too much fluid from the body in a matter of 4 hours (usual prescribed HD duration). And then, we have to emphasize to them the importance of their compliance. I, for example, would always tell my patients that they should not rely too much on hemodialysis as a means of removing excess fluids from their body, because there is a limit on the average amount of fluid that one hemodialysis treatment can remove. If they will not do their part, fluid will most likely accumulate in their body until it develops different complications that are much harder to manage. I realized that sometimes, you only have to explain further the process of therapy that your patient is going through to get their full participation in the course of care. Most of the time, patients who are not compliant are those who don’t understand the significance of their therapy, or those who have different opinions regarding his/her therapy or his/her condition.
In my experience, it is necessary for the nurses to know the patient’s perception regarding his/her condition and to explain the importance of following appropriate health care regimen. And then communicate ways that the patient could do to be able to arrive at a goal that will enhance his/her condition.
A fundamental goal of us nurses is to establish a trusting and harmonious nurse-patient relationship. King's goal attainment theory will help us in terms of achieving a certain goal in patient care. Important aspect is interacting and having an open communication with the patient, determining her/ his perceptions to own health care, setting a mutual objective, having mutual agreement with patient care which means involvement of the patient to her/his health management and achieving a desired outcome congruent to both the patient and the nurse's objective.
In my own experience in the medical ward, I encountered a patient admitted from having a hypertension and is restricted to perform activities, she was ordered to have complete bed rest without bathroom privileges. The physician also ordered low salt and low fat diet for the patient. She was on her third day of admission yet her BP won't stabilize. My fellow nurse would endorse her and found out that she is not following the physicians orders, she would get out from her bed and perform activities even walk to the comfort room. And also was not following her diet restrictions. What I did was explored her perceptions of her own health and knew that she is not aware why these restrictions was being implemented. I then, educated her of the importance of these restrictions to her condition and what to expect when these restrictions were not followed. The patient somehow, gained trust and we achieved a common objective to restore her functioning and stabilizing her BP. This one simple experience would determine the importance of a good nurse-patient relationship.
Establishing an interpersonal relationship with the patient would greatly influence the nursing process from gathering of data from the patient, to prioritizing health problems, setting objectives, implementing and attaining a set goal.
Imogene Kings theory is basically reminds me of setting and attaining goals to our client’s immediate recovery. I’ve learned that harmonious communication and agreement between me as his nurse and with my patient can make my nursing care plan achievable. I can still remember a client who’s suffering from acute bronchitis he’s complaining of difficulty of breathing as manifested by respiratory rate of 32 cpm, 102 pulse rate, wheezes is noted upon auscultating the his chest and productive cough. The doctor ordered to hook 02 inhalation via nasal cannula at 2-3 LPM and nebulize the patient every 6 hours. As I carried out the entire doctor’s order, I also made my nursing care plan and that is to ease or improve his breathing within my shift. As I put the patient in semi-fowler’s position for maximum lungs expansion, breathing is slightly improved. I also did chest and back clapping after the nebulization to loosen the phlegm and instructed him to do deep breathing exercise and relaxation. I explained every procedure and all the benefits it can bring so that he’s fully aware what will be the outcome. I noticed also his willingness to cooperate and at the end of the shift his breathing was improved. For me, as I inherited key concepts of King’s theory, that good interaction with the client, proper dispensing of information and putting in consideration the client’s culture, religion, social status etc. can make our nursing goal attainable. And winning trust and rapport to our client is very easy.
Imogene King Outline Health is the central notion on which nursing as a practice is founded upon. The idea of restoration of health plays a key role in every account of what nursing is. In the words of Imogene King, the goal of nursing is to help individuals and groups attain, maintain, and restore health.
Rapport is a process of building a sustaining relationship of mutual trust, harmony and understanding. It is essentially meeting individuals in their model of the world where we build a climate of trust and respect. I myself believe “Rapport is the key to influence”. It starts with acceptance of the other person's point of view, their state and their style of communication. To influence you have to be able to appreciate and understand the other person's standpoint. And these work both ways that I cannot influence you without being open to influence myself. It takes time to build rapport—time that we often think we can’t afford to spend. Yet a few essential steps can go a long way toward establishing trust with colleagues, patients, family members and other important people in your work and even personal life. To be an effective healthcare provider, we nurses needs to establish a close rapport with the patient, as both of them work towards a common goal, thus making communication and interaction a vital component of the whole treatment process. The ability to listen, a natural curiosity and empathy are among the essential qualities for a nurse needs to establish rapport with patients, families and colleagues. Lacking any of these qualities, the consequences can be disruptive, distressing and potentially damaging to those who feel they have not been heard or treated with respect. Dismissive behaviour and ineffective communication can negatively affect staff and their ability to help you and patients. Treating front-line personnel in a condescending way can build a wall.
