JOURNAL OF COMMUNITY HEALTH NURSING, 1996, 13(1), 51-57 Copyright © 1996, Lawrence Erlbaum Associates, In. Nursing Process for Health Promotion Using King’s Theory Mary L. Calladine, RN, MS D’Youville College Buffalo, NY ‘The purpose of this article is to describe a group experience for community health nurses. Using King’s (1981) theory of nursing as a guide, the aim was to maintain or promote the health of these nurses. As highlighted by Hanchett (1990), King’s theory can be inter- preted to view community health as reached through the deliberate activities of people and groups who perform as open systems in the transaction of energy through information. According to King, individuals make up one type of system in the environment, called personal systems. Individuals interact to form dyads, triads, and small and large groups. These make up yet another type of system called interpersonal systems. Groups with special interests and needs form organizations, which make up communities and societies and are called social systems. (p. 141) KING'S THEORY King (1981) defined community health as the continual adaptation to stressors through the best use of community resources in order to gain optimum potential. As a goal, according to King, community health is reached through deliberate activity of people and groups performing as open systems in the transaction of energy through information. Human interactions and goals are the center of the nursing assessment. The assessment content is organized according to concepts for the system levels, with communication being the most prominent concept at all levels. Goal-setting is the outcome of the assessment, and interventions are planned to assist the quality of interaction through increasing one’s perceptions and the caliber of communication (Hanchett, 1990). Requests for reprints should be sent to Mary L. Calladine, RN, MS, 190 McConkey Drive, Kenmore, NY 14223.52 = Calladine King (1990b) used the Goal Oriented Nursing Record (Table 1) which differs from other nursing records due to the added component of the goal list, which places importance on the use of her theory of goal attainment. This theory of goal attainment provides a way to devise a record for nurses’ actions and client progress. It also includes a record for the nurse to document the care given, actions, observations, and client responses. SELECTION OF TARGET GROUP The selection of the target group was based on the author’ experience in the community health setting and close contact with nurses who would be most beneficial to the group. I selected community health nurses because of the stressors they encounter in their everyday work. Stress exists to some degree in everyone’s life, and according to King (1981), health is the continual adaptation to stressors.The selection of the members subsequent to interviews included nurses who thought that stress was influencing their health The group consisted of six nurses, including one who had recently been promoted to supervisor. The group members, all women, ranged from 23 to 49 years old. They had a diploma or baccalaureate degree in nursing. RATIONALE FOR THE GROUP During the first meeting, the leader and group members set boundaries and identified the reasons for group therapy. Members were in agreement that anxiety and stress in the community health setting affected their physical and mental health. Assertiveness and time management were identified as precipitating factors. The group decided that these areas would be the focus of group meetings (see Table 2). TABLE 1 Goal Explore health maintenance and promotion problems Discuss what people in the group would like to address Process Encourage the expression of feelings Identify health promotion issues Goal oriented nursing record ‘Obtain a measurable data base and assess personal, interpersonal, and social systems Devise a problem list Mutually set goals Devise a plan Progress notes and revisions Outcomes Will be identified as goals attained that constitute measures of effectivenessGroup Process. 53 ASSESSMENT TOOL ‘The assessment tool selected was King’s (1991) Goal Oriented Nursing Record (Table 1). According to King, theory of goal attainment provides a way to design arecord for documenting nurses’ actions and patient progress. This documentation system also provides a permanent record that may be used by nurses to record and evaluate their observations, their actions, and the client's response to care. King stated that the use of reliable assessment tools provides data to be used in later research studies, The goals set and goals achieved provide a measure of the effectiveness of care. Increased autonomy in the home care field, along with increased workload due to case management, created stressors for these nurses. Pressures from management to conform to agency policies and procedures and effective time management appeared to be major issues that the group chose to focus on. Group members said they felt nursing was “a different profession” that most people don’t understand. Members said they felt that most TABLE2 implementation of Care Obtain a measurable data base (assessment) Personal Systems (individual) ‘Assess perception, self, growth and development, body image, space, and time Interpersonal Systems (groups) ‘Assess interactions, communications, transactions, role, and stress Social Systems (society) ‘Assess organization, power, authority status, and decision making Devise a problem list from data obtained ‘Anxiety related to increased workload and personal life Ineffective coping mechanisms related to stressors Powerlessness related to noncompliant patients Ineffective time management related to increased work demands Mutually set goals of the group ‘Anxiety will decrease upon group termination Effective coping mechanisms will be used ‘Time management will be used Assertiveness techniques will be used in personal and work environments Formulation of a plan Group members will identify their personal values and priorities Group members will have decreased anxiety by using techniques such as deep breathing and imagery Group members will develop proper coping mechanisms by using stress management techniques Group members will become familiar with assertiveness techniques and be capable of using them Progress notes and revisions Group meetings will be audiotaped with playback by the leader in order to assess group productivity and effectiveness. A log will also be kept to assist in evaluation. Outcomes will be reported as goals attained that constitute measures of effectiveness.54 Calladine people believe “nurses can handle anything” without taking the nurse’s personal andpro- fessional feelings into account. All members expressed feeling anxious and ineffective in regard to coping with personal and professional life styles. The group explored health maintenance and health promotion issues. The expression of feelings was encouraged throughout the group process. Discussion initially centered on each individual’s perception of health and factors that could and do alter one’s health. The results of the assessment tool combined with the knowledge gained during the first session assisted the leader in formulating the nursing diagnoses. NURSING DIAGNOSES King (1981) stated that nursing diagnoses identify the problems or disturbances for which the client seeks help. The following diagnoses were identified in relation to group meetings: 1. Anxiety related to increased workload and decreased self-esteem; 2. Potential ineffective coping related to stressors and multiple role expectations. GOALS King (1981) asserted that the goal of nursing is to assist the client to attain, maintain, or restore health, or to die with dignity. She proposed that goals should be mutually set, and that they are the means by which the client and nurse will achieve the optimal level of functioning for the client. After the diagnoses were formulated, goals were determined using King’s (1990a) theory of goal attainment. According to King, it is important that “individuals communicate information, mutually identify the goals to be attained, explore and agree on the means to the goal, and make transactions” (p. 128). The process of human interactions begins when two people come together as nurse and client. Perceptions of the interaction lead to judgments and actions. The actions lead to reactions, which result in the interaction of the two people. This interaction allows the two to identify the problem and mutually set goals, When the two have explored the means to attain the goal, they can move toward goal attainment, and a transaction has occurred (King, 1993) ‘The group members decided on the goals of learning stress management and stress reduction methods, assertiveness techniques, and time management skills. They said they felt that by using these techniques, they would be better equipped to handle the daily pressures within the community health setting. In King’s (1981) model, self-esteem is viewed as dynamic. The model takes into account values, beliefs, and self-preservation. Self-esteem influences motivation and change. Motivation is the willingness to do something; it is influenced by one’s values,Group Process 55 beliefs, and interactions with others and the environment. Change is the continual adjustment to stressors in internal and external transactions. It is a high priority in the hierarchy of values in society. ‘These phenomena influence the group as individuals and systems in that we are all part of systems. Our perceptions, values, and beliefs influence our motivation to change. All group members agreed that stress and anxiety were unhealthy. To facilitate change, the group explored measures to reduce anxiety, increase self-esteem, and better manage time. The use of self-evaluation tools, relaxation tapes, guided imagery (Hamm & O'Flynn, 1984), and handouts assisted in the process. INTERVENTIONS King’s (1981) concept of health and her theory of goal attainment, along with the systems model of groups, assisted the leader in determining appropriate interventions within this group. Observations, comments, and actions were continually assessed in order to determine techniques and evaluate effectiveness. The leader selected a prerecorded tape, “Instant Stress Relief: Mind Body Healing Tapes” (Bricklin, 1989). Side 1 of the tape included tips on ways to defuse stress. It discussed a new carbohydrate menu that relieves short-term stress, humor in the work- place, finances, and relationships. Ways to pinpoint stress areas were identified. Side 2 became a favorite of the group. It assisted listeners through deep-breathing relaxation techniques and used imagery to take members on a minivacation to a beach of their choice. The group members chose to listen to Side 2 of the tape at the beginning of each meeting. Itencouraged all present to truly relax and let go of the problems of the day. Handouts on ways to identify stress, relaxation techniques (Titlebaum, 1988), and exercises were used, and group members responded positively. Several members re- quested a copy of the tape, stating that they would like to continue to use the relaxation and imagery techniques even after completion of the group process. The leader took note of group interaction and what appeared to be decreased self-esteem in two members. Verbal and nonverbal cues were noticed. These included statements like “I don’t use positive coping mechanisms, mine are all unhealthy” and “I don't have time to do the things I enjoy.” The group then made lists of things they enjoy doing and shared them with one another. Group members offered positive feedback and reinforcement by pointing out the positive aspects in each other. One member reminded another of a concert she recently attended but failed to put on her list of things she enjoyed. One meeting was devoted to the topic of taking care of oneself. The leader read excerpts from “The Gentle Art of Self-Nurturing” (Heinrich & Killeen, 1983). Upon completion, the members listed ways in which they nurtured themselves, how long these activities56 Calladine took, and the last time they had done any of these activities. Many found they did not take enough time for themselves. All were then asked to set new goals. One chose to walk her dog every day for 15 min. The group as a whole decided that all members would take at least 15 min each day to spend on themselves, whether it was spent listening to music or taking a walk. Several meetings were devoted to assertiveness techniques by using Chenevert’s (1988) work, Special Techniques in Assertiveness Training. Although several members felt they lacked assertiveness knowledge, it was decided, after discussion, that they did not lack knowledge; they just needed to be more assertive in certain situations. One nurse stated she felt intimidated in certain clients’ homes because it was their “turf.” She felt the client was manipulative and that she gave her a “hard time” with appropriate nursing interventions. We then discussed the basic rights and responsibilities of women in health professions according to Chenevert. It was discussed that the client has the right to refuse treatment and that goals must be mutually set or frustration would result. Clients must agree to the interventions, because it is their right based on their own beliefs and values. Observations of the group interaction proved that younger members benefitted from the older members’ suggestions in this area. Another meeting was devoted to time management (McGee-Cooper, 1986). Dis- cussion involved the different ways the nurses used to manage their time. One article on time management had a brain hemisphere preference test, which the group took to determine which hemisphere they emphasized. Those who preferred the left hemi- sphere tended to use traditional time management techniques, such as to-do lists. Those who proved strong in the right hemisphere found traditional methods unman- ageable—they used more spontaneous techniques. It was then discussed that one could use both “brains,” because they are equally important and helpful. The right side promotes spontaneity, and the left deals with logic. Several suggestions to combine the two were discussed, and the group appeared pleased to discover that they had already been using the suggestion of taking some time out for themselves each day. EVALUATION According to King (1981), nursing interventions are be planned to facilitate the quality of interaction by increasing the accuracy of perception and the quality of interaction. Outcomes are to be identified as goals are attained. The goals attained in this group were decreased anxiety and effective coping mechanisms. By using relaxation techniques, imagery, assertiveness techniques, and time management, the group did achieve the goals listed in this article (see Table 2). In summary, King (1981) postulated that community health is the continual adaptation to stressors through the best use of community resources in order to gain maximum realization of potential. As a goal, King proposed that community health can be reachedGroup Process 57 through deliberate activity of people and groups performing as open systems in the transaction of energy through information. The success of this group experience validates that the use of King’s theory of nursing and goal attainment provides a guide for nursing practice and health promotion. Nurses can use this theory to assist the client to change his or her behavior to achieve an ideal model of wellness. REFERENCES Bricklin, M. (1989). Instant stress relief: Mind body healing tapes (Prevention Magazine Audiocassette] Emanus, PA: Rodale. Chenevert, M. (1988). Special techniques in assertiveness training (3rd ed.). St. Louis, MO: Mosby. Hamm, B., & O'Flynn, A. (1984). Teaching the client through guided imagery. Journal of Community Health ‘Nursing, 1, 39-45. Hanchett, ES. (1990). Nursing models and community as client. Nursing Science Quarterly, 3, 67-12. Heinrich, K., & Killeen, M. E. (1983). The gentle art of nurturing yourself. American Journal of Nursing, 93(10), 40-44. King, I. M. (1981). A theory for nursing: Systems, concepts, process. New York: Wiley. King, I. M. (1990a). Health asa goal for nursing. Nursing Science Quarterly, 3, 123-128. King, 1. M. (1990b). King’s conceptual framework and theory of goal attainment, In M. Parker (Ed.), Nursing theories in practice (pp. 73-84). New York: NLN. King, I. M. (1991). King’s theory of goal attainment. Nursing Science Quarterly, 5, 19-26. King, 1. M. (1993). Quality of life and goal attainment. Nursing Science Quarterly, 7, 29-32. McGee-Cooper, A. (1986). Time management: Cashing in on both brains. AORN Journal, 44, 178-183. Titlebaum, H. (1988). Relaxation. Holistic Nursing Practice, 2(3), 17-25.Copyright © 2002 EBSCO Publishing