N491 Module 4 assignment: King's conceptual system theory paper, a full sample

Agreeing on the Goal Before the Fall: King's Conceptual System and Theory of Goal Attainment Applied to Inpatient Fall Prevention

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RN to BSN Program, Aspen University

N491: Concepts and Theories in Nursing

Instructor Name

Month Day, Year

Agreeing on the Goal Before the Fall: King's Conceptual System and Theory of Goal Attainment Applied to Inpatient Fall Prevention

Imogene King developed a conceptual system for nursing made of three interacting systems, and from it she derived a middle-range theory of goal attainment. Her central claim is that nurses and patients who perceive a situation accurately, communicate, and agree on goals together are more likely to reach those goals (King, 1981). This paper explains the three systems with clinical examples, describes how they influence goal attainment, applies the theory to a common quality problem on medical units, patient falls, and proposes a quality improvement initiative based on mutual goal setting. It closes by showing how King's work aligns with Peplau's theory of interpersonal relations.

The Three Interacting Systems

King described human beings as open systems interacting with their environment at three levels (King, 1981). The personal system is the individual, understood through concepts such as perception, self, growth and development, body image, space, and time. A patient's perception of her own strength after three days in bed is a personal-system concept, and it may be very different from the nurse's assessment.

The interpersonal system is formed when two or more people interact, as in a nurse and a patient, or a nurse and a family. Its concepts include interaction, communication, transaction, role, and stress. The admission conversation in which a nurse and patient discuss how the patient will get to the bathroom at night is an interpersonal-system event. The social system is made up of larger groups with shared interests and goals, such as hospital units, families, and health systems, and its concepts include organization, authority, power, status, and decision making (Alligood, 2022). A unit's fall-prevention policy, staffing pattern, and rules about bed alarms belong to the social system.

How the Systems Influence Goal Attainment

The theory of goal attainment describes what happens inside the interpersonal system. The nurse and patient each perceive the situation, make judgments, and act; they react to each other, interact, and, when things go well, reach a transaction, an agreement on goals and on the means to achieve them (King, 1997). King proposed that when perceptions are accurate and transactions occur, goals are attained, and that goal attainment improves satisfaction and effective care.

The three systems shape whether a transaction is possible. In the personal system, a patient who perceives herself as independent may not accept a goal framed around dependence, such as calling for help every time. In the interpersonal system, rushed communication at admission may leave the nurse and patient with different ideas of the plan. In the social system, a unit culture that relies on alarms and signs rather than conversation may never create the space in which a transaction can happen. Goals imposed on a patient are not transactions in King's sense, and the theory predicts they will be attained less often.

A Clinical Quality Problem: Inpatient Falls

Few hospital harms are reported as often as falls, and older adults who fall during a hospitalization can suffer fractures, head injuries, and longer stays. Consider a composite 32-bed medical unit, described here for illustration, whose fall rate has stayed above its target for three quarters. A review of recent falls shows a pattern: most occurred at night, most involved patients walking to the bathroom alone, and most of those patients had been identified as high risk, had signs reading "Call, Don't Fall" in their rooms, and had agreed at admission to use the call light.

One case illustrates the problem. A 76-year-old woman admitted with cellulitis of the lower leg and receiving an evening diuretic fell at 3 a.m. on her way to the bathroom. When asked afterward why she had not called, she said she had waited a long time for help the previous night and did not want to wet the bed again. The goal of calling for help had been set for her, not with her, and it conflicted with a goal of her own, staying continent and dignified, that no one had asked about.

A Quality Improvement Initiative Based on Goal Attainment

The evidence supports a patient-centered approach. In a randomized trial in four hospitals, a fall prevention tool kit that tailored interventions to each patient's risk factors and communicated the plan to patients and families reduced falls, particularly among patients aged 65 and older (Dykes et al., 2010). A later study across 14 medical units found that a nurse-led tool kit designed to engage patients and families continuously in their own fall-prevention plan was associated with falls dropping by about 15 percent and injurious falls by about 34 percent (Dykes et al., 2020).

The proposed initiative applies King's theory directly. At admission and again each evening, the nurse asks each patient at risk what matters most about getting around at night, shares the nurse's own assessment of the risk, and reaches an agreement on a specific plan, such as scheduled toileting at 10 p.m., midnight, and 3 a.m., the diuretic timed earlier in the day with the prescriber's agreement, and a bedside commode. The plan is written on a bedside poster in the patient's words, which turns the transaction into a visible shared goal. On the social-system level, the unit sets a standard response time for call lights from high-risk patients at night and reviews each fall with the question King would ask: was the goal agreed, or assigned?

Success is measured by falls per 1,000 patient-days, compared with the previous four quarters, and by the percentage of high-risk patients with a documented mutually agreed plan. A short question at discharge, whether the patient felt the nighttime plan was one she helped make, adds a measure of the transaction itself.

Alignment With Peplau's Theory

King's theory aligns closely with Peplau's theory of interpersonal relations. Both make the bond between nurse and patient the core of nursing and treat it as a process that moves through stages toward a goal. Peplau emphasized that the patient and nurse come to understand the problem together and that the patient becomes more independent as the relationship progresses (Peplau, 1997). King's transaction resembles the point in Peplau's working phase at which the patient begins to make full use of the help available, and both theorists would recognize the fall in the case above as a failure of the relationship rather than of the patient.

The theories differ in emphasis. Peplau focused on the phases of the relationship and the roles the nurse plays, while King placed that relationship inside personal and social systems and offered testable propositions about goal attainment. Used together, Peplau explains how to build the relationship and King explains what it should produce: an agreed goal that both people are working toward.

Conclusion

King's conceptual system gives nurses a way to see any clinical problem at three levels at once, and her theory of goal attainment explains why agreed goals succeed where assigned ones fail. Inpatient falls show the theory at work: patients who agree to call for help while holding an unspoken goal of their own will often act on the goal that was never discussed. A quality improvement initiative that makes the nighttime plan a genuine transaction, supported by unit standards and evaluated by fall rates and by the patient's own sense of having shaped the plan, turns King's theory into a practical safety intervention.

References

Alligood, M. R. (2022). Nursing theorists and their work (10th ed.). Elsevier.

Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros, M. E., Lipsitz, S. R., Scanlan, M., Shaykevich, S., & Bates, D. W. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: A nonrandomized controlled trial. JAMA Network Open, 3(11), Article e2025889. https://doi.org/10.1001/jamanetworkopen.2020.25889

Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S., Tsurikova, R., Zuyov, L., & Middleton, B. (2010). Fall prevention in acute care hospitals: A randomized trial. JAMA, 304(17), 1912-1918. https://doi.org/10.1001/jama.2010.1567

King, I. M. (1981). A theory for nursing: Systems, concepts, process. Wiley.

King, I. M. (1997). King's theory of goal attainment in practice. Nursing Science Quarterly, 10(4), 180-185. https://doi.org/10.1177/089431849701000411

Peplau, H. E. (1997). Peplau's theory of interpersonal relations. Nursing Science Quarterly, 10(4), 162-167. https://doi.org/10.1177/089431849701000407