The nursing profession has significantly evolved from complete reliance and oversight of the physicians to independent dissemination and provision of healthcare interventions. This evolution is largely attributed to the changes in the policies and regulations governing the nursing practice, and more importantly, the concepts and propositions which form the theories that define and guide the practice. Nursing theories are the purposeful, systematic, and tentative structuring of ideas with regards to a particular phenomenon of healthcare provision ( Smith, & Parker, 2015). These theories have enabled the nurse practitioners to effectively evaluate and comprehend intricate patient situations, thereby enabling autonomy of the nursing profession. Several nursing theories have been proposed and implemented in clinical practice. The choice and application of the nursing theory are contingent on the healthcare needs of the target population and the clinical setting. Grand nursing theories are oriented on conceptual frameworks and address a broad scope of prepositions and concepts of the practice. Middle range nursing theories are more specific and provide a testable linkage between the grand theories and the nursing practice ( McEwen, Wills, 2017). These theories are often applied to specific clinical practice situations.
The King’s Conceptual System and Theory of Goal attainment and Transactional Process is a grand nursing theory provides a broad relationship between the nursing practice and the target population. The theory is based on the assumption that the primary focus of the nursing practice is human beings, with the main objective of the practice being the maintenance, restoration, and health ( McEwen, Wills, 2017). The theory asserts that the target population, which forms the frameworks within which the nurse practitioners operate, consists of individuals, families, and the community. The interactions and transactions of nurses within these frameworks are dependent on understanding human behavior. The transition nursing theory, on the other hand, is a middle-range theory based on the experiences that humans go through during the changes in their health situations. The theory is developed on the premise that a health event causes changes that before the event occurs and ends when the event is reverted. During these changes, nurse practitioners play a vital role in understanding health events and providing appropriate interventions ( Tappen, 2016). The transition theory highlights that the primary goal of the nursing profession is to conceptualize and resolve health issues through effective nurse-patient interactions. In this regard, the theory points out that it is imperative for the nurses to understand the nature and patterns of the transitions.
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Background of the Theories
Imogene King first proposed King’s conceptual model and the theory of goal attainment in the mid-1960s. King perceived that the organization and use of a nursing knowledge base were vital in the application of nursing concepts and modalities of care interventions. This perception led to the development of King’s conceptual system in 1971. This system was founded on four concepts: health, interpersonal relations, perceptions, and social systems ( Smith, & Parker, 2015). According to King, these concepts are universal to the nursing practice and are, therefore, integral in the development and application of nursing theories. The identification and selection of these concepts and consequently, the development of the conceptual system were based on critical thinking, synthesis and in-depth review of nursing and related literature, and deductive and inductive reasoning. The concepts were further expanded to include the nature of the healthcare environment, explicit description of the social systems and social interactions, and personal aspects of self-growth and development, time, space, perception, and image. The process model of human interactions and personal and interpersonal systems formed the basis of the theory of goal attainment, which was developed in 1981 ( McEwen, Wills, 2017). This theory specifically aimed to address and improve how nurses interact with their patients for better achievement of their health goals. Subtle changes have been made to the theory, including the addition of the concepts of learning and coping, expansion of the concept of stress to include stressors, and the redefinition of space.
The development of the transition theory began in 1960 when Afaf Meleis was researching the phenomena of pregnancy planning and parental roles. The interaction and communication of spouses were central in Meleis’s research, in which she postulated that the spousal interaction and communication was integral in family planning. This research later shifted to the role of supplementation and the nature of changes in human healthcare experiences ( Meleis, 2015). This led to extensive research and review of nursing and clinical practice literature on healthcare experiences of different patients and population groups. These changes and experiences included immigration, surgery, chemotherapy interventions, aging, and motherhood. The empirical evidence gathered from these studies formed the basis for the development of the theory, which focused on how the transitions framework influenced the individuals’ health and wellbeing ( Meleis, 2015). The situation-specific theories that were developed from these studies were later consolidated into the transitions theory in 2010.
Philosophical Underpinnings of the Theories
King’s conceptual system and theory are based on von Bertalanffy’s General Systems Model. In 1968, Ludwig von Bertalanffy proposed that a system comprises of an intricate interaction of elements, in which the elements are free to interact with their surroundings. The interactions are self-regulating and often form the premise of the evolution of the elements. The system theory is a science of wholeness, in which the collective characteristics cannot be defined from the characteristics of the isolated parts. King acknowledged that the General Systems Model made it possible to study the nursing practice wholesomely ( McEwen, Wills, 2017). Interactions are the antecedents of King’s theory. In relation to the General Systems Model, the human interactions and in particular, the nurse-patient interactions constitute the interactions of elements with their environment.
Major Assumptions, Concepts, and Relationships
King’s conceptual system and theory highlight several assumptions at the individual, nursing, and nurse-individual interactions. At the individual level, the theory assumes that individuals’ behaviour is action-oriented, controlling, time-oriented, and purposeful. It also assumes that individuals are rational, sentient, reacting, and social beings. At the nursing level, the theory assumes that (1) nursing entails thinking and acting in line with the needs of the individuals seeking care; (2) nursing is intrinsically the care of human beings; and (3) the nursing situation provides an environment for the interaction of two individuals with the intent of coping with the prevailing events. At the nurse-individual level, the theory assumes that (1) the effectiveness of the interaction is influenced by the perceptions of client and nurse; (2) it is the rights of individuals to have positive interactions with nurses; (3) the needs, values, and goals affect the interaction process; and (4) the goals of both parties may not be similar ( McEwen, Wills, 2017).
The major concepts of King’s theory are nursing, health, perception, environment, communication, interaction, transaction, individuals, health, and stress. As the primary concept, nursing is described as the actions, interactions, and reaction in a situational environment in which the nurse and the client share their perceptions, concerns, problems, and goals and evaluate ways of attaining the goals ( McEwen, Wills, 2017). These concepts are organized into useful prepositions that describe the complex relationships within the theory. The major relationships highlighted in the theory are: (1) Congruence in the perception, actions, needs, and values of the nurse-client interactions lead to specific orientation of goals; (2) accuracy is required in the interactions for transactions to occur; (3) the nurse and client have to make transactions for goals to occur; and (4) satisfaction and effective nursing care is realized if goals are attained ( McEwen, Wills, 2017).
Similarly, the transitions nursing theory is also based on some assumptions at the nursing, individual, environment, and health level. The theory assumes that (1) nurses are the primary caregivers for individuals undergoing transitions; (2) transitions are both the cause and consequence of change; (3) transitions cause changes in the person’s roles, identities, behaviour, abilities, health, and relationships; (4) transitions are multidimensional and intricate; and (5) the environmental conditions, transition experiences and interactions predispose individuals to vulnerability ( Meleis, 2015).
The major concepts of the theory are transitions, interactions, facilitators, inhibitors, and nursing therapeutics. Transitions are characterized by “properties” and “patterns”. The properties may refer to the engagement., change difference, events, and critical points, while patterns may be single, multiple, related, sequential, simultaneous, or unrelated. Facilitators and inhibitors of the transition may include the community and societal conditions, socioeconomic status, personal perceptions and meanings, knowledge, and preparation ( Meleis, 2015). These relationships of the theory are based on the interactions of the concepts. The major relationships of the transition theory are process and outcome indicators, which are the results of healthy transactions. Establishing effective nursing therapeutics is contingent on positive transactions between the client and the nurse.
Clinical Application and Testability
King’s goal attainment theory has widely been applied in the development and enhancement of nursing education and practice. The concepts of the theory were the premise of the baccalaureate nursing program various nursing schools both in the United States and globally. The model provides an organizing guide for clinical nursing practice. Although the models may vary in different institutions, the inherent concept and phenomenon of “wholesomeness” is fundamental across all practice disciplines. The applications and usefulness of King’s model vary widely from nursing information systems to diagnosis and therapeutic interventions. However, the theory cannot be applied in specific clinical practice due to its lack of specificity. Parts of the theory are adapted in line with the needs or requirements of the individual or healthcare provider ( Fronczek, Rouhana, & Kitchin, 2018). The model has also been tested and used as a conceptual framework in a of number of research.
The transition theory is readily and widely applicable in clinical practice, providing a framework for the evaluation and consideration of cultural and social diversity. There is evidence of increasing empirical evidence and applicability of the theory in the nursing practice, with a focus on the nursing speciality areas. The integration of the concepts of the theory and the complexity of the nursing science enables the nurse practitioners to recognize and understand how the transitions affect the caregivers, healthcare systems, and most importantly, the patients ( McEwen, Wills, 2017). Due to its affinity, applicability and comprehensiveness, the transition theory can be extrapolated to a wide scope of clinical practice and human phenomena such as birth, illness, mortality, recovery, and immigration. It is useful in explaining clinical situations, including diagnosis, prognosis, hospitalization, and hospital discharge. Besides being generalized to the wide clinical situations and patient phenomena, the theory can also be personalized to focus on the unique experiences of clients in health transitions ( Smith & Liehr, 2018), thereby promoting the delivery of effective care.
Comparison of the Use in Nursing Practice
King’s theory of goal attainment is a grand nursing theory and therefore, less specific to clinical practice situations. The theory is, however, important in forming conceptual frameworks for guiding the broad nursing practice. King’s theory provides a framework for the nurse-patient interaction in clinical practice, which occurs in every transaction of the care process. The interaction occurs during the assessment of the client, in which the nurse collects the patient’s data and uses it to form the perception and diagnosis of the patient’s condition. After the perception is formed, the nurse and the client discuss the planning of the appropriate interventions and the goals of the interventions, after which the nurse implements the intervention agreed upon ( Caceres, 2015). On the other hand, the transitions nursing theory is comprehensive, has a high affinity, and specific for the clinical situations. Phenomena such as illness and recovery, for example, are fundamental events in clinical situations. Nurses play an important role in the restoration and maintaining health. By diagnosing illnesses and resolving health challenges, nurses are essentially applying the concepts of transition theory to enable the patients to cope with the challenges of their health changes ( Rees, 2017).
Application to Specific Clinical Setting
In the geriatric patient care, King’s theory of goal attainment provides a framework for my inter5action with individuals, families, and groups with the specific purpose of understanding their needs, setting health goals, developing and implementing strategies for the attainment of the goals. For a patient that checks into the clinic, interaction and communication with the patient begin at the initial meeting. Geriatric patients are at high risk of Alzheimer’s disease ( Sizer, Burton, & Harris, 2016). This may impede effective nurse-patient interaction and therefore make it difficult to obtain important information pertinent to the assessment and development of care. Since King’s model is based on wholesome interactions and communication in the care environment, I need to develop positive interpersonal relations with the patient and their family. This will enable me to understand better understand the patient’s needs, set their goals, and develop effective intervention measures for attaining the goals.
The transitions theory in geriatric care is useful in understanding the patient’s experiences with the aging and the development of aging conditions such as Alzheimer’s disease and dementia. Important transitions in geriatric patients include transfer to nursing care homes, separation from their families, diagnosis of Alzheimer’s disease and dementia, cessation of normal life activities and roles such as professional duties, financial constraints, and preparation for end-of-life ( Sizer, Burton, & Harris, 2016). Throughout all these transitions, the patient may exhibit behavioural changes. It is therefore important for the nurse practitioner to understand the nature and patterns of the transition, as well as the facilitators and inhibitors such as separation from family and interaction with peers, respectively. This analysis is imperative in developing the care required and resolving health challenges.
Parsimony
King’s goal attainment theory is not parsimonious as it has several concepts that form many relationships at different levels. Also, the theory has many assumptions and statements that further highlight the complexity of the theory. However, it can be argued that complexity represents the underlying intricacy of nursing science ( McEwen, Wills, 2017). Similarly, the transitions theory has numerous assumptions that might interfere with its clinical application in practice. However, the transitions theory is relatively less complex because it is founded on only four primary concepts which interact at the clinical practice level. The transitions theory is thus parsimonious.
Conclusion
The evolution and autonomy of the nursing practice are largely due to the development, adoption, and implementation of the nursing theories in clinical practice. Many theories have been developed in history. These theories are categorized as grand theories or middle-range theories, depending on their specificity and application in clinical [practice. The King’s conceptual system and goal attainment theory is a grand theory founded on the nurse-client interactions at various social levels with the purpose of attaining certain health gaols. The transitions nursing theory is a middle-range nursing theory that is based emphasizes the patients’ experiences during changes in certain health and life phenomena. Given the differences in patients needs and the concepts of the theories, the adoption and implementation of the theories in clinical practice vary. The nurse practitioner is integral in applying the theories in clinical practice. It is important for the NP to understand the theoretical concepts and determine the best intervention approaches for the realization of optimum health outcomes.
References
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Fronczek, A. E., Rouhana, N. A., & Kitchin, J. (2018). Applying King’s Conceptual Framework and Theory of Goal of Attainment: Telehealth Content in Nursing Education.
McEwen, M., & Wills, E. M. (2017). Theoretical basis for nursing . Lippincott Williams & Wilkins.
Meleis, A. I. (2015). Transitions theory. Nursing theories and nursing practice , 4 , 361-380.
Rees, C. E. (2017). Transitions in health professional education: Theory, research and practice. Focus on Health Professional Education: A Multi-disciplinary Journal , 18 (3), 4.
Sizer, S. M., Burton, R. L., & Harris, A. (2016). The influence of theory and practice on perceptions about caring for ill older people–A literature review. Nurse education in practice , 19 , 41-47.
Smith, M. C., & Parker, M. E. (2015). Nursing theories and nursing practice . FA Davis.
Smith, M. J., & Liehr, P. R. (Eds.). (2018). Middle range theory for nursing . Springer Publishing Company.
Tappen, R. M. (2016). Advanced nursing research: From theory to practice . Jones & Bartlett Publishers.
