See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/274089186

King’s Theory of Goal Attainment: Exploring Functional Status

Article  in  Nursing Science Quarterly · April 2015

DOI: 10.1177/0894318415571601 · Source: PubMed

CITATIONS READS
8 34,086

1 author:

Billy A Caceres
Columbia University
76 PUBLICATIONS   555 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Obesity and weight-related behaviors in sexual minority youth View project

Sexual Minority Women's Health in Latin America and the Caribbean: A Scoping Review View project

All content following this page was uploaded by Billy A Caceres on 19 January 2016.

The user has requested enhancement of the downloaded file.

571601
research-article2015
NSQXXX10.1177/0894318415571601Nursing Science QuarterlyCaceres

Article

Nursing Science Quarterly

King’s Theory of Goal Attainment:

2015, Vol. 28(2) 151­–155
© The Author(s) 2015
Reprints and permissions:
Exploring Functional Status sagepub.com/journalsPermissions.nav
DOI: 10.1177/0894318415571601
nsq.sagepub.com

Billy A. Caceres, RN; MSN1

Abstract
Imogene King’s Theory of Goal Attainment provides a schema for nurses interested in functional status. However, the lack
of a uniform definition for functional status has hindered development of a concise understanding of this phenomenon.
Functional status is particularly important to nurses who are concerned with the safety and wellbeing of clients. With
healthcare’s increased focus on client-family-centered care it is important to develop innovative approaches for evaluating
functional status that incorporate the client-family perspective. King’s focus on mutual decision-making is an underutilized
resource that can provide great insight into the study and understanding of functional status.

Keywords
functional status, King’s theory, nursing theory, patient care

The purposes of this article are to (a) evaluate and define the
phenomenon of functional status, (b) highlight its impor-
tance to nursing, and (c) describe how King’s Theory of Goal
Attainment (TGA) can be used to enhance communication
and shared decision-making for nurse-client dyads and for
nurse researchers who seek to improve and understand func-
tional status. Functional status is conceptualized in varying
ways by different health professions (National Committee on
Vital & Health Statistics [NCVHS], 2000). Leidy (1994)
underscored the confusion that arises from conflicting defi-
nitions that are either too broad or too narrow in their view of
functional status. Regardless functional status has important
implications for the nursing profession, since nurses are con-
cerned with the health and wellbeing of clients. Rowe (1996)
asserted that functional status is an important outcome for
nursing research as it has considerable economic and policy
implications. Yet few researchers have applied King’s theory
to the study of functional status.
Undoubtedly, King’s TGA underscored the importance of
nurse-client dyads and client perception. During the last
decade there has been a shift toward client-family-centered
care, which encourages collaboration among healthcare pro-
fessionals, clients, and their families. Client-family-centered
care promotes client satisfaction by encouraging clients and
their families to engage in open communication with provid-
ers (Institute for Patient & Family Centered Care, 2010).
One-size-fits-all approaches to healthcare are inconsistent
with client-family-centered care. Thus, King’s TGA is more
relevant than ever as healthcare has placed increased empha-
sis on client needs and preferences. King’s TGA provides an
important lens through which to evaluate the nurse-client
dyads’ implications for goal-setting and client satisfaction
related to functional status.
Conflicting Definitions of Functional
Status
Establishing a clear definition of functional status is marred
by conflicting definitions that have been formulated by dif-
ferent professions (NCVHS, 2000). The perspective by
which one investigates functional status profoundly affects
the way it is defined and examined. The challenges for nurs-
ing are differentiating what elements of functional status are
relevant to nursing and demonstrating how nurses can influ-
ence the functional status of clients.
In some disciplines functional status is quantified by an
individual’s ability to participate in activities of daily living,
such as eating, bathing, toileting, transferring, and dressing
(NCVHS, 2000). With this lens functional status is directly
tied to physical capabilities as mediated by a disease’s effects
on sensory functions such as vision and touch. More compre-
hensive views of functional status tend to include the social,
cognitive, psychological, and spiritual domains (Van Cleave,
Egleston, & McCorkle, 2011). Van Cleave and colleagues
(2011) view functional status in relation to performing activ-
ities necessary to fulfill current life roles such as parent,
employee, student, and others. Accentuating life roles as an
aspect of functional status highlights the social domain.
Further complicating the discourse about functional status
is that health status, functional ability, and quality of life are
used interchangeably with functional status (Leidy, 1994).
Leidy (1994) asserted that current definitions of functional
status are either too broad or narrow. She said that Katz and
Stroud’s Activities of Daily Living (ADL) and Lawton and
Brody’s Instrumental ADLs lack the concept of capacity of
1
PhD Student, New York University College of Nursing, New York, NY
152 Nursing Science Quarterly 28(2)
an individual to perform tasks (Leidy, 1994). She proposed a
definition of function that includes ability to carry out basic
needs, fulfill social roles, and maintain health and wellbeing
as part of everyday life.
Thus, Leidy (1994) developed a multidimensional frame-
work in which functional status is distinguished from the
concepts of functional performance, functional capacity,
functional reserve, and functional capacity utilization.
Functional capacity is described as an individual’s full poten-
tial to participate in their lives and it applies to every domain
(Leidy, 1994). Functional performance refers to the actual
activities one must perform and includes the physical, men-
tal, social and spiritual domains but precludes the cognitive.
In Leidy’s framework the cognitive domain is tied to perfor-
mance in that it can impede an individual from recognizing
or achieving full functional capacity due to a lack of per-
ceived benefit. Next, functional reserve is essentially the dif-
ference between functional capacity and functional
performance. It is higher in individuals who either (a) may
not realize their potential capacity; or (b) are unable to per-
form at their highest functional level. The more individuals
use the resources at their disposal to achieve their highest
function in each domain the higher their functional capacity
utilization (Leidy, 1994).
Similar to Leidy (1994), others have utilized conceptual
frameworks to study functional status. For instance, Chen,
Hung, Lin, Haung and Yang (2011) developed a model for
examining functional status that includes the domains dis-
cussed by Leidy (1994) with the exception of the spiritual
domain. Likewise, Ade-Oshifogun (2012) elaborated Leidy’s
framework by incorporating elements of the Wilson and
Cleary model, which inspects the relationship between dis-
ease symptoms and functional status. On the other hand,
Song and Lee (1996) use an ecological framework to define
and study functional status. They identified performance as a
behavior that is a function of the interplay between an indi-
vidual’s functional capacity and the environment as medi-
ated by emotional wellbeing. Moreover, Rowe (1996)
utilized resource theory to examine internal and external
resources that influence function. Internal resources are psy-
chological in nature and include resilience and self-esteem.
External resources are defined by social networks and may
include participation in social and religious activities (Rowe,
1996).
King’s Conceptual System
To understand King’s TGA, one must first examine her con-
ceptual system. King first presented her conceptual system in
a 1968 article. Subsequently she expanded on this work in
her 1971 book Toward a Theory of Nursing. King’s concep-
tual system had been referred to by various names including
open systems model, interacting systems framework, and
general systems framework until she formally defined it as
such in 1997 (Fawcett, 2004).
King’s thoughts on nursing theory were heavily influenced
by what she viewed as a dearth of theory within the discipline.
In her opinion nurse leaders were too concerned with how the
profession was practiced but not why it was practiced that way
(Fawcett, 2004). King asserted that theory could bridge this
gap and expose unexplored dimensions of the profession.
Accordingly, she believed establishing a theoretical body of
knowledge was vital for nursing to advance (Fawcett, 2004).
Reflecting on the roots of her work, King (1995) delineated
three major hurdles to nursing theory development in the
1960s which included (a) lack of professional language; (b)
anti-theoretical bias in the profession; and (c) nursing as a pro-
fession had not been adequately differentiated from other
fields. Her disappointment in the state of nursing science at the
time led King to explore literature of other disciplines includ-
ing organizational psychology, philosophy, and most notably
general systems (King, 1981). She was also influenced by the
work of pragmatist philosopher John Dewey (Fawcett, 2004).
As described by King (1981) she sought to develop a frame-
work that would serve as the foundation of a theory that would
illuminate the “why” of nursing (p. 281). This directly led to
the development of her TGA.
The basic tenet of her conceptual system is that human
beings are open systems in constant interaction with the
environment (King, 1995). Human beings as open systems
are reactive beings who are action and goal-oriented (King,
1995). The goal of the system is health. The relation between
TGA and functional status is evident in that King defined
health in terms of functional ability and how fully individu-
als are able to perform their social roles (Alligood, 2010).
Health is an interaction between the human being and the
environment (King, 1995). Although all humans are open
systems, their motivations, desires, and needs vary widely
and their goals are directly influenced by personal values
(King, 1995). King (1995) viewed these values as normative
and directly influenced by culture. Thus the health goals one
individual might identify may be vastly different from indi-
viduals of different cultures or even those from within the
same cultural group.
Furthermore, the main concepts of King’s conceptual sys-
tem are multidimensional and include: the personal, interper-
sonal, and social systems. Table 1 delineates the main
components of each system. These three systems are in con-
stant interaction and interrelated. Resources may range from
the tangible such as money, property, and food; to intangible,
which may include self-esteem, social support, and resil-
ience; or lack thereof. These resources become part of the
system as inputs through interaction with the environment
(King, 1971). Individuals utilize these inputs through mental
and physical activities, which then create outputs. Outputs
refer to an individual’s behavior and goal-setting, which
Caceres 153
Table 1.  Components of King’s conceptual system.
Personal Interpersonal Social
Perception Interaction Organization
Self Communication Authority
Growth & Development Transaction Power
Body Image Role Control
Time Stress Status
Personal Space Coping Decision-making
Learning  
have a direct influence on overall health and function
(Fawcett, 2004).
It is important to highlight several factors of the personal
and interpersonal systems presented in Table 1 that are
essential to understand King’s TGA. Perception, a compo-
nent of the personal system, is central to King’s notion of
transactions, which is the exchange that occurs between
individuals and the environment. Likewise, the self is what
makes individuals who they are. It includes memories and
the subjective environment of the mind (King, 1981).
Humans are constantly changing and evolving and the envi-
ronment facilitates this process, referred to as growth and
development (King, 1981). The final dimension of the per-
sonal system is learning. It was added in the 1980s and is
based on sensory perceptions, which can be evaluated by
observable behaviors exhibited by the individual (King,
1981). The interpersonal system can consist of two or more
individuals interacting with one another (King, 1971).
Interaction is the process of individuals communicating
with one another and developing perceptions of these
encounters. These perceptions help form judgments that
influence actions and future encounters (King, 1981).
Communication is the vehicle that establishes relationships.
Communication can be non-verbal or verbal and includes
all activities that tie human beings together (King, 1981).
Transaction refers to meaningful interactions that take
place between individuals and the environment with the
purpose of achieving goals. The nurse is crucial to transac-
tions since King views goal attainment as the purpose of the
nurse-client relationship. Transactions occur when nurse-
client interactions lead to goal attainment (King, 1981).
Role is influenced by the social systems’ imposed ideas of
what behaviors are associated with a particular role. For
instance the role of parent is directly tied to preconceived
notions of how a parent should behave. Success in the role
of parent is based on the standards set by social systems
(King, 1981).
It is evident that King’s conceptual system is complex and
multifaceted. The interaction of all factors within the three
systems is integral to goal attainment. Nurses must under-
stand the importance of these systems and their interactions
with the environment in order to help clients set goals that
meet their needs (Fawcett, 2004).
King’s Theory of Goal Attainment
King’s TGA is derived from her conceptual system and
incorporates the concepts of self, perception, growth and
development, space, time, interaction, communication,
transaction, role and coping (Goodwin, Kiehl & Peterson,
2002). King developed the TGA to present a practice meth-
odology based on nursing theory that applied the proposi-
tions presented in her conceptual system (Clarke, Killeen,
Messmer & Sieloff, 2009). Furthermore, King’s TGA is
based on the nursing process, which includes the following
stages: assessment, diagnosis, planning, implementation,
and evaluation. She viewed the nursing process as central to
goal-setting and goal-attainment in nurse-client interactions
(Goodwin et al., 2002; Alligood, 2010). In fact, Goodwin
and colleagues (2002) asserted that the North American
Nursing Diagnosis Association (NANDA) used King’s TGA
in developing their list of nursing diagnoses.
According to Alligood (2010) there are four basic propo-
sitions to the TGA (a) goals are attained through nurse-client
interactions; (b) the nurse-client must perceive one another
and their motives accurately for transactions to occur; (c)
role expectation and performance must be congruent; (d)
nurses must use their knowledge and skills to mutually set
goals, communicate information, and aid clients in achieving
their goals. Moreover, this interaction-transaction process
forms the basis of the TGA and is based on the nursing pro-
cess. The assessment phase is represented by the concepts of
perception, judgment, action, and reaction. In this phase the
nurse and client begin to interact with one another and form
judgments about the other (King, 1992). Action and reaction
are mediated by perception and judgment and represent the
thoughts the nurse and the client have about one another’s
motives, behaviors, and goals. King’s Goal Oriented Nursing
Record (GONR) is used in the assessment phase to record
the nurse’s perception of the client. The diagnosis phase is
represented by disturbance. Disturbance is the act of the
nurse inquiring about the client’s environment, personal and
interpersonal systems (King, 1992). King developed the
Criterion-Referenced Measure of Goal Attainment Tool
(CRMGAT) to record client’s goals, roles, values, perceived
stressors, and environment. The CRMGAT and GONR can
be continuously updated to reflect changes in the client’s
goals and perceptions (King, 1981). After the planning phase
the mutual goal-setting, exploration of means to achieve
these goals, and agreement of these means form the imple-
mentation phase of TGA (King, 1981). The implementation
phase of TGA seeks to increase accountability of the nurse-
client dyad to follow the prescribed plan. The outcome of
TGA is determined by communication between the nurse
and the client in which the client’s state of health and ability
to function in social roles help determine if goals were
attained. If not attained, the client and nurse must discuss
factors that prevented the goal attainment. This represents
the evaluation phase of the nursing process (King, 1981).
154 Nursing Science Quarterly 28(2)
The client is at the center of this process and involved at
every stage.
The elements of the TGA reflect the nurse-client relation-
ship and are in continuous interaction with one another.
Therefore, the nurse and client are influenced by one anoth-
er’s perceptions, judgments and actions, which influence
their relationship and subsequently goal attainment. TGA is
open and non-linear which fosters continuous assessment
and opportunity for the nurse and client to re-visit steps of
the process prior to evaluating outcomes. For instance, at the
diagnosis phase the nurse and client may revisit the assess-
ment before continuing to the planning phase (Fawcett,
2004).
King asserted that goal-setting and goal attainment are the
core of the nurse-client relationship. Her work has been used
in a variety of healthcare situations and countries around the
world. For example, in 1995 the TGA was used by three dif-
ferent researchers to examine families coping with children
diagnosed with mental illness, goal-setting for children with
chronic disease, and the role of goal-setting in family func-
tioning (Alligood, 2010). Cho (2013) used a health contract
intervention derived from TGA with dialysis patients in
Korea. Draaistra, Singh, Ireland and Harper (2012) utilized
TGA in a qualitative study in Canada examining clients with
spinal cord injuries and their perceptions of their involve-
ment in goal- setting.
Functional Status and Nursing
Through the use of King’s TGA it is evident that functional
status is a phenomenon of concern for nursing. As recog-
nized by King, functional status is a crucial aspect of nursing
as nurses are concerned with the care of clients in all facets
of their lives. The four central phenomena of nursing are the
person, environment, health, and nursing (King & Fawcett,
1997). In evaluating functional status these four factors are
to be considered as any disruption of these factors can impede
a client’s capacity to perform fully. For this reason Leidy
(1994) called for nursing to focus on developing a clear defi-
nition of functional status in order to improve the quality of
client care.
Rowe (1996) highlighted the importance of outcomes in
nursing research. Rowe (1996) argued that functional status
has become an important outcome in nursing research with
great economic considerations that require the attention of
nurses. Song and Lee (1996) contended that clients with poor
functional status require more comprehensive nursing care
therefore increasing healthcare costs. Thus, the cost and pol-
icy implications of poor functional outcomes are important
to consider (Rowe, 1996). This is evident through the inclu-
sion of function as one of the Healthy People 2020 objectives
(United States Department of Health & Human Services,
2011). In an era where there is increased concern about pro-
viding quality and cost-effective care, functional status is a
clear outcome that nursing initiatives can target to reduce
costs.
The Theory of Goal Attainment and
Functional Status
King viewed health as directly related to functional status
claiming that function is more than physical ability (Alligood,
2010). For that reason an individual’s ability to fulfill social
roles contributes to health status (King, 1981). King’s notions
about functional status and nursing are similar to those of
Leidy (1994). Both view function as a composite of several
domains of an individual’s life beyond physical capacity. It is
apparent that functional status may be viewed from different
perspectives. Some may focus on the objective features of
functional status while others emphasize the subjective.
Under King’s TGA functional status is a multi-factorial con-
cept that is heavily influenced by individual client percep-
tions and current roles. Clients’ perceptions of their functional
status are as important as nurses’ assessments of function. As
described in King’s TGA goal-setting is central to under-
standing functional status. Every individual client has a dif-
ferent set of functional status goals. Similarly, not all
individuals aim to fulfill the same roles in life. Therefore,
clients cannot be compared based on objective criteria as
effective or ineffective at meeting functional status goals.
Moreover, King’s TGA is based on the notion that clients
must be involved in their own care (Clarke et al., 2009).
However, it is through interaction with the nurse that transac-
tions can influence a client’s behavior. With the focus on
goal-setting and client involvement in care it is evident how
TGA can be applied to examine function in clients. TGA’s
four basic propositions relate to functional status and the role
of nurses. As nurses gain experience in their practice they
become adept at assessing when clients are functioning at
their fullest potential based on their medical condition. It is
important for nurses to apply this experiential knowledge in
interactions with clients not only to assess their goals but
also to aid clients in understanding their functional capacity.
Confusion can arise when role expectation and performance
are not clear. For example, clients who have a surgical proce-
dure that limits functional status must work with nursing
staff to (a) set mutually established goals for function; (b)
understand how they are progressing toward their functional
goals; (c) delineate their expectations of the nursing staff in
helping them achieve these goals and (d) work in collabora-
tion with nurses to adapt goals as needed. The success of the
nurse-client dyad in this situation depends on the expertise
and skills of the nurse to help guide clients in accomplishing
goals. Nevertheless, the client’s willingness to participate as
an equal partner in decision-making and care planning is just
as important to goal attainment as the expertise of the nurse.
In evaluating studies that utilize King’s TGA and concep-
tual system it is evident that her work is relevant today. Yet
few studies used King’s work to evaluate the functional sta-
tus of clients. King’s TGA was created for the purpose of
nursing practice (King, 1981). As noted by Frey, Sieloff, and
Norris (2002), King’s earlier work had a quantitative slant
but as her ideas about health and the nurse-client relationship
 Caceres 155
developed she acknowledged the value of qualitative meth-
ods for exploring nursing phenomena. Accordingly, Fawcett
(2004) viewed King as pragmatic in her approach to goal-
setting. Thus a researcher could use either quantitative or
qualitative methods when employing the TGA to study func-
tional status. Quantitative methods to examine function
might employ objective measures to track goal attainment
including King’s GONR, Katz and Stroud’s ADL and Lawton
and Brody’s Instrumental ADLs. A relevant research ques-
tion may be: “How do goal-oriented nurse-client dyads influ-
ence outcomes in older adults?” On the other hand, a
qualitative study may evaluate clients’ perceptions of their
function and their ability to attain goals. Draaistra and others
(2012) utilized a qualitative method to gain understanding of
the perceptions of clients about their involvement in their
setting goals following spinal cord injury. Also, a researcher
may posit questions to nurses who use this theory when
working with clients such as: “What do you think your role
is in client goal setting?” or “What are the attitudes of nurses
and clients about goal oriented nurse-client dyads?”
Conclusion
King’s conceptual system and TGA have important implica-
tions for those interested in examining functional status. With
healthcare’s increased emphasis on client needs King’s work
may help nurses improve the health and experience of client
and families. Clinical nurses, nurse researchers, and nurse
administrators may glean much from King’s focus on the
nurse-client dyad as central to the attainment of goals.
Although defining functional status is a critical step in study-
ing this phenomenon, the frameworks developed by Leidy
(1994) and others provide varying ways of evaluating func-
tional status. Functional status is directly tied to the metapara-
digm of nursing and nursing’s concern for client safety and
wellbeing and is therefore a significant phenomenon for
researchers to study. Functional status is an important outcome
in healthcare that deserves increased attention from nurses and
other health professionals. King’s work provides a useful lens
for nurses to assess the functional status of clients and to guide
nursing practice to provide client-family-centered healthcare.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this editorial.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this editorial.
References
Ade-Oshifogun, J.B. (2012). Model of functional performance in
obese elderly people with chronic obstructive pulmonary dis-
ease. Clinical Scholarship, 44(3), 232-41. doi: 10.1111/j.1547-
5069.2012.01457.x.
View publication stats
Alligood, M.R. (2010). Family healthcare with king’s theory of
goal attainment. Nursing Science Quarterly, 23(2), 99-104.
doi: 10.1177/0894318410362553.
Chen, K.M, Hung, H.M., Lin, H.S., Haung, H.T., & Yang,
Y.M. (2011). Development of a model of health for older
adults. Journal of Advanced Nursing, 67(9), 2015-25. doi:
10.1111/j.1365-2648.2011.05643.x.
Cho, M.K. (2013). Effect of health contract intervention on renal
dialysis patients in korea. Nursing & Health Sciences, 15, 86-
93. doi: 10.1111/nhs.12003.
Clarke, P.N., Killeen, M.B., Messmer, P.B., & Sieloff, C.L. (2009).
Imogene M. King’s scholars reflect on her wisdom and influ-
ence on nursing science. Nursing Science Quarterly, 22(2),
128-33. doi: 10.1177/0894318409332568.
Draaistra, H., Singh, M.D., Ireland, S., & Harper, T. (2012).
Patient’s perceptions of their roles in goal setting in a spinal
cord injury regional rehabilitation program. Canadian Journal
of Neuroscience Nursing, 34(3), 22-30.
Fawcett, J. (2004). Contemporary nursing knowledge: Analysis
and evaluation of nursing models and theories (2nd Ed).
Philadelphia, PA: F.A. Davis Company.
Goodwin, Z., Kiehl, E.M., & Peterson, J.Z. (2002). King’s theory
as a foundation for an advanced directives decision-making
model. Nursing Science Quarterly, 15(3), 237-41.
Institute for Patient and Family Centered Care. (2010, December
29). Frequently asked questions. Retrieved from http://www.
ipfcc.org/faq.html
King, I.M. (1971). Toward a theory for nursing: General concepts
of human behavior. New York, NY: Wiley.
King, I.M. (1981). A theory for nursing: Systems, concepts and pro-
cess. New York, NY: Wiley.
King, I.M. (1992). King’s theory of goal attainment. Nursing
Science Quarterly, 5, 19-26.
King, I.M. (1995). A systems framework for nursing. In M.A.
Frey & C.L. Sieloff (Eds.), Advancing king’s systems frame-
work and theory of nursing (pp. 14-22). Thousand Oaks, CA:
Sage.
King, I. M., & Fawcett, J. (Eds.). (1997). The language of nursing
theory and metatheory. Indianapolis, IN: Center Nursing Press,
Sigma Theta Tau International.
Leidy, N.K. (1994). Functional status and the forward progress of
merry-go-rounds: Toward a coherent analytical framework.
Nursing Research, 43(4), 196-202.
National Committee on Vital & Health Statistics. (2000). Clarifying
and reporting functional status. Retrieved from: http://www.
ncvhs.hhs.gov/010617rp.pdf
Rowe, M.A. (1996). The impact of internal and external resources
on functional outcomes in chronic illness. Research in Nursing
& Health, 19, 485-97.
Song, M., & Lee, E. (1996). Development of a functional capac-
ity model for the elderly. Research in Nursing & Health, 19,
173-81.
United States Department of Health & Human Services. (2011).
Healthy People 2020: Older Adults. Retrieved from: http://
www.healthypeople.gov/2020/topicsobjectives2020/objec-
tiveslist.aspx?topicId=31
Van Cleave, J., Egleston, B.L., & McCorkle, R. (2011). Factors
affecting recovery of functional status in older adults after can-
cer surgery. Journal of the American Geriatrics Society, 59,
34-43. doi: 10.1111/j.1532-5415.2010.03210.x.