Communication and Human Relation in Nursing (2)

7/31/2019 Communication and Human Relation in Nursing (2)

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COMMUNICATION AND HUMAN RELATION IN NURSING

INTRODUCTION

We live in an age and culture where efficiency and productivity mean a great deal. We

have become obsessed with matters of technique and our technological skills have developedtremendously. This has extended from industry and commerce to this profession, which deal more

directly with human beings and their welfare. We are busy doing things and at times we are

working and for whom we are also human beings. Here comes the importance of communication

and human relations in our profession. Communication is a lifelong learning process for the nurse.

Together with the client and family, nurses make the initiate journey from the miracle of birth to

the mystery of death.

COMMUNICATION

DEFINITION

Communication is the transmission and interchange of facts, ideas, feelings of action.

[Leland Brown]

Communication is the interchange of thought or information to bring about mutual

understanding and confidence or good human relation.

[American Society of Training Directors]

Communication is the process of passing information and understanding from one person

to another. It is the process of imparting ideas and making oneself understood by others.

[Theo Haiemann]

Communication is the process of sharing experience till it becomes a common possession.

It modifies the disposition of both who partakes it.

(John Dewey)

Communication is the process by which information, meaning and feelings are shared

through the exchange of verbal and nonverbal messages between two or more people.

(Brooks and Health 1993)

CONCEPT OF COMMUNICATION

Communication is a process involving the writing selecting and sending of symbols in such

a way as to help the listener perceive and recreate in his/her own mind the meaning contained in


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the mind of the communicator. Communication involves the certain of meaning in the listener, the

transfer of information and thousands of potential stimuli. Communication enables as to grow to

learn to be aware of ourselves and to adjust to our environment.

The word communication is derived from the Latin word commnis which means

common. It is the process of exchange of facts, ideas, opinions and means that individuals or

organizations share meaning and understanding with one another. Communication may have a

more personal connotation than the interchange of ideas or thoughts. It can be a transmission of

feelings or a more personal and social interaction between people.

Communication contains both the elements of a science and art. The science of

communication provide a body of principles which can guide the managers to find a solution to the

specific problems and objective evaluation of results. Communication is creative like an art. It

develops new situations, designs and new systems needed for further improvement.

Communication art and communication science are interwoven and overlapping in nature.

The art of communication is as old as human history, but the science of communication is an

event in the recent past the emergence of communication as a district and leading technology is a

pivotal event in a Social history.

THEORIES OF COMMUNICATION

I. BULLS EYE THEORY

Action view is the basis for the theory of communication. The whole process

ofcommunication is based on one-way action doing something to someone. The sender

plays an important role who encodes the message with the help of arbitrary symbols. The

demonstration or doing skills of the sender is for the purpose to change the behavior of

receiver. The action believes that words have a meaning and there would be no

misunderstanding, which is the core of effective communication, provided the right words

are used to convey the right message. Misperceptions or misunderstandings are bound to

occur but according to information theory, the sender has to play effectively and

adequately.

II. PING-PONG THEORY

This theory is also called interaction or interpersonal view. This approach to the

study of human communication is the Ping-Pong theory of communication. Ping-Pong isthe game of table tennis, represents the interaction theory of communication. It is compared

with turns at a table tennis match. In communication process, the turns take place between


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the sender and the receiver. It is a complex theory of communication than the Bulls theory

which recognizes the concept of linear feedback. In this theory, there is linear cause and

effect.

III. SPIRAL THEORY

The spiral theory of communication is called as transactions view of communication. It

recognizes more than one interaction between sender and the receiver. A transaction

implies independence, mutual and reciprocal causality. Myers and Myers say that human

communication is best understood as a system in which senders are simultaneously

receivers and senders. Communication is not static but dynamic and life time experience.

THE COMMUNICATION PROCESS

Face to face communication involves a sender, a message, a receiver and a response, orfeedback. In its simplest form, communication is a two way process involving the sending and the

receiving of a message. Because the intent of communication is to elicit a response, the process is

ongoing, the receiver of the message then becomes the sender of a response, and the original

sender then becomes the receiver.

SENDER

The sender, a person or group who wishes to convey a message to another, can be

considered the source-encoder. This term suggests that the person or group sending the message

must have an ideas or reason for communicating (source) and must put the idea or feeling into a

form that can be transmitted. Encoding involves the selection of specific signs or symbols (codes)

to transmit the message, such as which language and words to use, how to arrange the words and

what tone of voice and gestures to case. The nurse must not only deal with dialects and foreign

languages but also must cope with two language levels. The laypersons and the health

professionals.

MESSAGE

The second component of the communication process is the message itself- what is actually

said or written, the body language that accompanies the words, and how the message is

transmitted. The medium used to convey the message is the channel, and it can largest any of the

receivers senses. It is importantfor the channel to be appropriate for the message and it should help

make the intent of message more clear.

Talking face to face with a person may be more effective in some instance than telephoning

or writing a message. Recording messages on tape or communicating or communicating by radio

or television may be more appropriate for larger audiences. Written communication is often


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appropriate for long explanations or for a communication that need to be preserved. The non-

verbal channel of touch is often highly effective.

RECEIVER

The receiver, the third component of the communication process, is the listener, who must

listen, observe and attend. This person is the decoder, who must perceive what the sender intended.

Perception uses all of the senses to receive verbal and nonverbal messages. To decode means to

relate the message perceived to the receivers store house of knowledge and experience and to sort

out the meaning of the message. Whether the message is decoded accurately by the receiver,

according to the senders intent, depends largely on their similarities in knowledge and experience

and sociocultural background. If the meaning of the decoded message matches the intent of the

sender then the communication has been effective. In effective communication occer. When the

message sent is misinterpreted by the receiver.

RESPONSE

The fourth component of the communication process, the response, is the message that the

receiver returns to the sender. It is also called feedback. Feedback can be either verbal or non-

verbal of both. Non-verbal examples are nod of the head or a yawn. Either way, feedback allows

the sender to correct or reword a message. Now the original sender becomes the receiver, who is

required to decode and respond.

MODES OF COMMUNICATION

Communication is generally carried out in two different modes : verbal and non-verbal.

Verbal communication uses the spoken or written word; non-verbal communication uses other

forms such as gestures or facial expressions and touch.

1. VERBAL COMMUNICATION

Verbal communication is largely conscious because people choose the words they use. The

words used very among individuals according to culture, socio economic background, age and

education. In addition, a wide variety of feelings can be conveyed when people talk. When closing

words to say or write, nurses need to consider.

a. Pace and intonation.

b. Simplicity.

c. Clarity and brevity.

d. Timing and relevance.


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e. Adaptability.

f. Credibility.

g. Humor.

a. Pace and intonation

The manner of speak, as in the pace or rhythm and intonation, will modify the

feeling and impact of the message. The information can express enthusiasm, sadness, anger

or amusement. The pace of speech may indicate interest, anxiety, boredom, or fear. For

example, speaking slowly and softly to an excited client may help calm the client.

b. Simplicity

Simplicity includes the use of commonly understood words, brevity and

completeness. Many complex technical terms become natural to nurses. Words such as

vaso constriction or cholecystectomy are meaningful to the nurse and easy to use but are ill

advised when communicating with clients. Nurses need to learn to select appropriate

understand able terms based on the age, knowledge, culture and education of the client.

c. Clarity and brevity

A message that is direct and simple will be more effective clarity is saying precisely

what is meant and brevity is using the fewest words necessary. The result is a message that

is simple and clear.

d. Timing and relevanceNurse need to be aware of both relevance and timing. When communicating with

clients. No matter how clearly or simply words are stated or written, the timing needs to be

appropriate to ensure that words are beard. Moreover, the message need to relate to the

person or to the persons interests and concerns.

e. Adaptability

Spoken messages need to be altered in accordance with behavioral cues from the

client. This adjustment is referred to as adaptability. What the nurse says and how it is said

must be individualized and carefully considered. This requires astute assessment and

sensitivity on the part of the nurse.

f. Credibility

Credibility means worthiness of belief, trust worthiness, reliability. Credibility may

be the most important criterion of effective communication. Nurse foster credibility by

being consistent, dependable and honest. The nurse needs to be knowledgeable about what

is being discussed and to have accurate information. Nurse should convey confidence and

certainty in what they are saying, while being able to acknowledge their limitations.


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g. Humor.

The use of humor can be a positive and powerful fool in the nurse client

relationship, but it must be used with care. Humor can be used to help clients adjust to

difficult and painful situations. The physical act of laughter can be both an emotional and

physical release, reducing tension by providing a different perspective and promotion a

sense of well-being.

2. NONVERBAL COMMUNICATION

Nonverbal communication is sometime called body language. It includes gestures, body

movements, use of touch, and physical appearance, including adornment. Nonverbal

communication offer tells others more about what a person is feeling than what is actually

said, because non-verbal behaviours is controlled less consciously then verbal behaviours.

Observing and interpreting the clients non-verbal behaviours is an essential skill for nurse

to develop.

PERSONAL APPEARANCE

Clothing and adornments can be sources of information about persons. Although choice of

apparel is highly personal, it may convey social and financial status, culture, religion, group

association and self-concept. How a person dresses is often an indicator of how the person feels.

Someone who is tired or ill may not have the energy or the desire to maintain their normal

grooming. For acutely ill client is hospital or home care settings, a change is grooming habits may

signed that the client is feeling better. A man may request a share or a woman may request a

shampoo and some makeup.

POSTURE AND GAIT

The ways people walk and carry themselves are often reliable indicators of self-concepts

current mood and health. Erect pasture and an active, purposeful stride suggest a feeling of

wellbeing. Slouched pasture and a slow, staffing gait suggest depression or physical discomfort.

Tens posture and a rapid determined gait suggest anxiety or anger.

FACIAL EXPRESSION

No part of body is as expressive as the face. Feelings of surprise, fear, anxiety, anger,

digest, happiness and scenes can be converged by facial expression. Nurse need to be aware to

their own expressions. Nurses need to be aware of their own expressions and what they are

communication to others. Clients are quick to notice the nurse facial expression. Particularly when

the patient feels unsure or uncomfortable. Eye contact is another essential element of facial


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communication. A person who feels weak or defenseless often events the eyes or avoids eye

contact, the communication received may be too embarrassing.

GESTURES

Hand and body gestures may emphasize and clarify the spoken work, or they may occur

without words to indicate a particular feeling or to give a sign. A father awaiting information about

his daughter in surgery may wring his hands, tap his foot, picks at his nails or pace back and forth.

A gesture may more clearly indicate the size and shape of an object. For people with special

communication problems, such as the deaf, the hands are invaluable in communication problems,

such as the deaf, the hands are invaluable in communication.

MODELS OF COMMUNICATION

1. Aristotle model

The first step towards development of a communication model has been taken by

Aristotle. He had developed an easy, simple and elementary model of communication

event, there are three ingredients and they are speakers, speech and audience.

2. David.K.Berlos Model

David Barks process theory is one of the basic theories for all communication

theorists. In this model, be identified essential elements and also other factors affecting

them such as five senses. This model does not consider verbal and non-verbal stimuli. The

following nine components are included in this model

3. Linear Model

One way communication or one directional communication is explained in linear

model of communication. According to this, a speaker encode a message and sends it to alistener through one or more of the sensory channels. The listener then receives and

decodes the message.

SOURCE ENCOUER MESSAGE CHANNEL RECEIVER DECPDER

FEED BACK

NOISE

MEANING


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4. Interaction model

In this model the source, encodes a message and sends it to the receiver through one

or more sensory channels. The receiver then decodes the message received. The receiver

then encodes the feedback and then sends the feedback to the source, making it two way or

interaction communication

FACTORS INFLUENCING COMMUNICATION

There are many factors that influence communication and they are

i. Development factors.

Age, development tasks.

ii. Environmental factors.

Noise, privacy, comfort and safety, distraction.

iii. Situational factors

Stress, pain and discomfort, fear and anxiety, dyspnea, fatigue, hearing

impaired, selective listening.

iv. Social factors

Gender, social class, language, power, social scripts, social roles, education.

v. Cultural factors

Standards of communication, canquage, etnnicity, custom, self expression

pattern values and beliefs.

vi. Psychological factors

Emotions, defense mechanisms, attitudes, assumptions, prejudices,perceptual distortions.

Source

Encodes

Message

Listener

Decodes

Message

Source

Encodes

Message

Listener

Decodes

Message

Channel

Channel


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LEVELS OF COMMUNICATION

Nurse use different levels of communication in their daily practice.

A. INTRAPERSONAL COMMUNICATION

It is a powerful form of communication that occurs within an individual. This level of

communication is also called self-talk, self-verbalization and inner thought. Nurses and

patients can use intrapersonal communication to develop self-awareness and a positive self-

concept by positive talk and defeating negative thoughts.

B. INTERPERSONAL COMMUNICATION

It is on to one interaction that occurs face to face. This level of communication is

frequently used in nursing situations. It results in expression of feelings, exchange of ideas,

decision making, team building, goal accomplishment, problem solving and personal

growth when happens meaning fully.

C. TRANSPERSONAL COMMUNICATION

It is the interaction that occurs within apersons spiritual domain. Nurses who value human

spiritually use this level for patients and for themselves.

D. SMALL GROUP COMMUNICATION

It is interaction that takes place with gathering of group dynamic. Nurses use this form for

committee work, to lead client support group, form research team and so on.

E. PUBLIC COMMUNICATION

It is the interaction with an audience. Nurse use this form for group health education, class

room discussion with students or peers.

F. ORGANIZATIONAL COMMUNICATION

It is the interaction between an individual and groups within an organization in order to

achieve established goals.


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SEVEN CS OF COMMUNICATION

1. CREDIBILITY

Communication starts with the climate of belief which is built by performance o the part of

the practitioner. The performance reflects an earnest desire to serve the receiver and

receiver must have confidence in the sender.

2. CONTENT

The message must have meaning for the receiver and it must be compatible with his/her

value system. The content determines the audience.

3. CONTEXT

A Communication program must square with realities of its environment. The context must

confirm, not contradict the message.

4. CHANNELS

Different channels have different effects.

5. CLARITY

Complex issues should be compressed into themes that have simplicity and clarity.

6. CAPABILITY

Communication must take into account the capability of receiver. Communication is most

effective when they require the least effort on the part of the receiver.

CREDIBILITY

CONTINUITY

AND

CONSISTENCY

CONTENT

CLALTY

CHANNELS

CONTEXT

CAPABILITY


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7. CONTINUITY AND CONSISTENCE

Communication is an unending process. Repetition with variation contributes to factual and

attitude learning, the content must be consistent.

FUNCTIONS OF COMMUNICATION

1. Instructive Function

The communication transmits the necessary directives and guidance as to enable them to

accomplish his/her tasks.

2. Integration Function

It involves bringing about interrelationship among various functions.

3. Informing Function

The function or purpose of communication is to inform the individual or group about the

subject.

4. Evaluation Function

It is tool to appraise the individual.

5. Directive Function

Communication is necessary to issue directions by top management to the lower level.

Directing others cannot take place without a complete communication process.

6. Influencing Function

It implies the provision of feedback which reflects the effect of communication.

Motivational forces in an individual are to be provided and then stimulated through

communication.

7. Interview Function

Interviews selects qualified and worthy people for enterprise. Recruitment process implies

facetoface oral communication.

8. Teaching Function

A complete communication process is required to teach and educate the health workers

with regard to procedures, ensuring safety needs of patients, policies, cost control etc.

9. Orientation Function

Communication helps to make people acquainted with colleagues and superiors withpolicies, rules and regulations of the institution. Similarly nurse orients the newly admitted

patient to the word through communication.


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10.Decision Making Function

Communication either verbal or written helps the process of decision making such as a

nurse following data collection arrives at a nursing diagnosis and decides a problem solving

technique.

STRUCTURE OF COMMUNICATION

In traditional framework of organization communications are largely structures ie, they go

through authorized channels. The channels of communication is terms of structure include

a. Downward communication

b. Upward communication.

a. Downward Communication

It means the flow in from higher to lower authority. This is usually considered to be from

management to employees. It may be oral or written.

Eg: - Personal instructions, bells and signals, circulars, bulletins, notices etc.

b. Upward Communication.

Here the information must be fed upwards to enable management to enable management to

evaluate the effectiveness with which its orders have been carried out as well as to become the

basis of fresh orders and directions. It may also be oral or written.

Eg: Meeting, conferences, face to face talks etc.

BARRIERS OF COMMUNICATION

The word Barriers means hindrances or hurdles or difficulties or problems. Any difficulty

which party or fully prevents an activity is called a barrier. Barriers with reference to

communication imply hurdles or problems on the way which adversely affect the transmission of

information form sender to the receiver.


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1. Organizational Barriers

These barriers arise when duties and tine of authority are not clearly defined. They

arise on the account of distance communication, more layers of communication, heavy

communication load etc.

Eg:- Policy, Rules and Regulations, Status and Position etc.

2. Semantic Barriers

Problems of language are called semantic barriers. They arise on account of linguistic

background and ability of the communicator. Linguistic barriers occur in both oral and

written communication common types of semantic barriers are:

Badly expressed Message.

Jargon Language.

Unclarified assumptions.

Faulty translations.

3. Personal Barriers

a. Barriers to supervisors

- Prejudice

- Complex

- Regard- Attitude.

b. Barriers in subordinates

- resistance to new idea.

- Lack of encouragement.

4. Psychological Barriers.

Poor pronunciation.

Confused thinking. Communication overload.

Attitude.

Fear and anxiety.

Lack of interest.

5. Physical Barriers.

Environmental disturbances.

Physical health. Poor hearing.

Distance.


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6. Mechanical Barriers

Non-availability of proper machines.

Presence of defective machines.

Interruption.

Power failure.7. Cross Cultural Barriers

Culture

Political beliefs.

Ethics and values.

Rules and regulations.

8. Perceptional Barriers

Lack of common experience. Linguistic.

Look of knowledge of any language

Low I.Q

9. Interpersonal Barriers

Withdrawal.

Rituals.

Pastimes10.Gender Barriers

Women want empathy not solutions are more likely to compliment emphasize

politeness.

Men - works out problems on a individualized basis.

- Are more directive in conversation.

- Call attention to their accomplishments

- Tend to dominate discussions during meetings.METHODS TO OVERCOME BARRIERS OF COMMUNICATION

The above said barriers can be thought of a fitter, that is, message leaves the sender, goes

through these filters and then received by the receiver which may muffle the message. The

following strategies can be adopted to overcome such fitters.

SUITABLE LANGUAGE

The appropriate language and tone definitely minimizes linguistic banners to

communication. Use of technical terms should be avoided as per as possible and the message


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should be direct simple and meaningful language. Different people perceive the message

differently. The term should use common language to avoid semantic distortions.

ACTIVE LISTENING

Hearing and listening is not the same. Hearing is the act of perceiving sound. It is

involuntary and simple refers to the reception of a rural stimuli. Listening is a selective activity

which involves the reception and the interpretation of rural stimuli. It involves decoking the sound

into meaning.

EVALUATIVE

Making a judgment about the worth, goodness or appropriateness of the persons statement.

FEED BACK

When you know something say you know. When you do not know something say that you

do not know. That is knowledge. The purpose of feedback is to alter messages so the intention of

the original communicator. It includes verbal and non-verbal responses to another persons

message. Carl Rogers listed five categories of feedback.

- Evaluative

- Interpretive

- Supportive

- Probing

- Understanding

ACTION AND DEEDS

Communication through actions and deeds is the principle of effective communication. A

message is one to be acted upon. Otherwise it tends to distort the current and also the message

hence forth from the individuals involved in communication. A meaning to a message is achieved

only when it is acted upon. Action and words must hand in hand.

CLARITY

Every communication should have skills to have clarity of the message. The greater part

relies on the sender of the message to achieve clarity. The message should be as clear as possible

in the mind of sender. The purpose of communication is to make the receiver understand the

message which can be achieved through clarity.


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KNOWING THE RECEIVER

The importance of understanding the receiver and the needs of the receiver cannot be over

looked. The message content is to meet the needs of the receiver. Sender of message should have

capabilities, back ground and level of intelligence, social climate, receptiveness, temperament, and

attitudes and soon.

INTER PERSONAL RELATIONSHIP

Developing optimum interpersonal relationship can be more helpful in overcoming the

barriers of communication. Lack of co-operation among people results in non-accomplishing their

goal. Principles of personal contact, appreciation, recognition and so on help in eliminating the

barrier.

COMMUNICATION AND THE NURSING PROCESS

Communication is an integral part of the nursing process. Nurses are communication skills

in each. Phase of the nursing process. Communication is also important whencaring for clients

who have communication problems. Communication skills are even more important when the

client has sensory, language or cognitive deficits.

ASSESMENT

To assess the clients communication the nurse determines communication impairment or

barriers and communication style. Remember that culture may influence when and how a client

speaks. Obviously, language varies according to age and development with children, the nurse

observes sounds, gestures and vocabulary.

DIAGNOSIS

Impaired verbal communication may be used as a nursing diagnosis when an individual

experiences a decreased, delayed or absent ability to receive, process, transmit and use a system of

symbols anything that has meaning. Communication problem may be receptive (eg.difficulty

haring) or expressive (eg. difficulty speaking). Nursing diagnosis used for clients experiencing

communication problems that involve impaired. Verbal communication include the following,

Anxiety related to impaired verbal communication.

Social isolation related to impaired verbal communication.

Impaired social interaction related to impaired verbal communication.


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PLANNING

When a nursing diagnosis related to impaired verbal communication has been made, the

nurse and client determine outcomes and begin planning ways to promote effective

communication. The overall client outcome for persons with impaired verbal communication is to

reduce or resolve the factors impairing the communication.

IMPLEMENTING

Nursing interventions to facilitate communication with clients who have problems with

speech or language include manipulating the environment, providing support, employing measures

to enhance communication and educating the client and support person. A quiet environment with

limited distractions will make the most of the communication efforts of both the client and the

nurse and increase the possibility of effective communication. The nurse should conveyencouragement to the client and provide nonverbal reassurance, perhaps by touch if appropriate.

EVALUATING

Evaluation is useful for both client and nurse communication. To establish whether client

outcomes have been met in relation to communication, the nurse must listen actively, observe non-

verbal cues and use therapeutic communication skills to determine that communication was

effective. For nurses to evaluate the effectiveness of their own communication with clients, process

recordings are frequently used.

Application of Theory of Goal Attainment

This page was last updated on October 17, 2011

O B J E C T I V E S

to assess the patient condition by the various methods explained by

the nursing theory

to identify the needs of the patient

to demonstrate an effective communication and interaction with the

patient.

to select a theory for the application according to the need of the

patient

to apply the theory to solve the identified problems of the patient

to evaluate the extent to which the process was fruitful

I N T R O D U C T I O N

Kings theory offers insight into nurses interactions with individuals


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and groups within the environment.

It highlights the importance of clients participation in decision that

influences care and focuses on both the process of nurse-client

interaction and the outcomes of care.

Mr.Sy (74 years) was admitted in L3 ward of ...Hospital, for a

herniorrhaphy on ... for his left indirect inguinal hernia and was

expecting discharge from hospital... the theory of goal attainment

was used in his nursing process.

C O N C E P T S A N D D E F I N I T I O N S

1. Interaction

A process of perception and communication

Between person and environment

Between person and person

Represented by verbal and nonverbal behaviours

Goal-directed

Each individual brings different knowledge , needs, goals, past

experiences and perceptions, which influence interaction

2. Communication

Information from person to person

Directly or indirectly

Information component of interaction

3. Perception

Each persons representation of reality

4. Transaction

Purposeful interaction leading to goal attainment

5. Role

A set of behaviours expected of persons occupying a position in a

social system

Rules that define rights and obligations in a position

6. Stress

Dynamic state

Human being interacts with the environment

7. Growth and development

Continuous changes in individuals

At cellular, molecular and behavioural levels of activities


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Helps individuals move towards maturity

8. Time

Sequence of events

Moving onwards to the future

9. Space

Existing in all directions

Same everywhere

Immediate environment (nurse and client interaction)

N U R S I N G P A R A D I G M S

Nursing

Observable behaviour

In health care system in society

Goal to help individuals maintain health

Interpersonal process of action; reaction, interaction and transaction

Person

1. Social beings

2. Sentient beings

3. Rational beings 4. Perceiving beings

5. Controlling beings

6. Purposeful beings

7. Action oriented beings

8. Time oriented beings

Health

Dynamic state in the life cycle

Continuous adaptation to stress To achieve maximum potential for daily living

Function of nurse, patient, physicians, family and other interactions

Environment

Open system

Constantly changing

Influences adjustment to life and health

Dynamic Interacting Systems

PERSONAL SYSTEM

Concepts


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Perception

Self

Body image

Growth and development

Time

Space

INTERPERSONAL SYSTEM

Concepts

1. Interaction

2. Transaction

3. Communication

4. Role

5. Stress

SOCIAL SYSTEM

Concepts

1. Organization

2. Authority

3. Power

4. Status,

5. Decision making

A S S U M P T I O N S

Basic assumption of goal attainment theory is that nurse and client

communicate information, set goal mutually and then act to attain

those goals, is also the basic assumption of nursing process.

Perceptions, goals, needs and values of the nurses and client

influence interaction process

Individuals have the right to knowledge about themselves and to

participate in decisions that influence their life, health and community

services Health professionals have the responsibility that helps individuals to

make informed decisions about their health care

Individuals have the right to accept or reject health care

Goals of health professionals and recipients of health care may not

be congruent

P R O P O S I T I O N S

From the theory of goal attainment king developed predictive propositions,

which includes:

If perceptual interaction accuracy is present in nurse-client

interactions, transaction will occur


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If nurse and client make transaction, goal will be attained

If goal are attained, satisfaction will occur

If transactions are made in nurse-client interactions, growth &

development will be enhanced

If role expectations and role performance as perceived by nurse &

client are congruent, transaction will occur

If role conflict is experienced by nurse or client or both, stress in

nurse-client interaction will occur

If nurse with special knowledge skill communicate appropriate

information to client, mutual goal setting and goal attainment will

occur.

N U R S I N G P R O C E S S

A s s e s s m e n t

King indicates that assessment occur during interaction. The nurse

brings special knowledge and skills whereas client brings knowledge

of self and perception of problems of concern, to this interaction.

During assessment nurse collects data regarding client (his/her

growth & development, perception of self and current health status,

roles etc.)

Perception is the base for collection and interpretation of data.

Communication is required to verify accuracy of perception, for

interaction and transaction.

The first process in nursing process is nurse meets the

patient and communicates and interacts with him.

Assessment is conducted by gathering data about the

patient based on relevant concepts.

Mr. Sy is 74yrs married, got admitted in L3 ward of

...Hospital on 27/03/08 with a diagnosis of indirect

inguinal hernia underwent herniorraphy with prolene

mesh done on 30/03/08. The following areas were

addressed to for gathering data.

What is the

patients

perception of the

situation?

Patient says I have undergone

surgery for hernia. The wound isgetting healed, I have no other

problem I have pain in the area of

surgery when moving Im taking

medicines for hypertension for the

last 7 years from here I have

vision problem to my left eye. I had

undergone a surgery for my right

eye about 10 years back.

What are myperceptions of the

situation?

Patient underwent herniorahaphy

operation on 30th March for indirectinguinal hernia which he kept

untreated for 35 years. Patient has

health maintenance related

problems. Patient is at risk of


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developing infection. Patient has

pain related to surgical incision.

Patient may develop hypertension

related complications in future.


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What other

information do I

need to assist this

patient to achieve

health?

HISTORY

Identification details

Mr. Sy is 74yrs married, male,

studied up to 7th Std is doing

Business, a practicing Muslim, gotadmitted in L3 ward of ...Hospital on

27/03/08 with a diagnosis of indirect

inguinal hernia underwent

herniorraphy with prolene mesh

done on 30/03/08.

Present History of Illness Abdominal

swelling for 35 years with difficulty

in activities and occasional

abdominal pain. He has

hypertension for seven years. Theswelling remained stable with

uncomplicated progress, getting

increasing size when standing for

long and reducible on applying

pressure No h/o severe pain but

increasing size for the last few years

Relived after pressing the swelling

back to position and on taking rest

and applying pressure.

Past health history Patientunderwent cataract surgery about 10

years back On treatment for

hypertension No other significant

illness

Family History Patients next elder

brother and next younger brother

had inguinal hernia and were

operated Elder brother underwent 3

surgeries for hernia

Socioeconomic Status High economic

status >Rs.20000/- per month.

Life Style Non vegetarian No habit of

smoking or alcoholism. Aware about

health care facilities

Physical examination Alert,

conscious and oriented Moderately

built, adequate nourishment, withBMI of 22 Vital signsnormal

except BP 140/90 mmHg General

head-to-foot examination reveals

normal finding except for the vision

difficulty of the right eye and healing

surgical wound on the left inguinal

region. Subjective problems Pain at


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Physical examination Alert,

conscious and oriented Moderately

built, adequate nourishment, with

BMI of 22 Vital signsnormal

except BP 140/90 mmHg General

head-to-foot examination reveals

normal finding except for the visiondifficulty of the right eye and healing

surgical wound on the left inguinal

region. Subjective problems Pain at

the surgical wound site Lack of

bowel movement for 2 days Review

of relevant systems

GI system Inspection: Healing

wound, No infection, No redness, No

swelling.

Auscultation: Normal bowel

sounds

Palpation No pain at the site,

Normal abdominal organs

Percussion: No dull sound

suggesting fluid collection or

ascitis

Genito-Urinary system

Inspection: Testicles inposition, No infection, No

swelling or enlargement.

Palpation No c/o pain,No

prostate enlargement

Percussion No fluid collection

in scrotum

Auscultation Normal Bowel

sounds Laboratory

Investigations

FBS - 91 mg/dl

Na(130-143mEq/dl) - 134

mEq / dl

K+ (3.5-5 mg/dl) - 3.5 mEq /

dl

Urea(8-35mg/dl)-29 mg / dl

Sr. Cr (0.6-1.6 mg/ dl)-


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What does this information means to

this situation?

Patient neglected a health problem for 35 years

Ptiient has acute pain at the site of surgical wound

Patient has family history of inguinal hernia and

risk for recurrence

Patient has a risk for recurrence due to

constipation. Patient has risk for infection due to inadequate

knowledge and age.

Patient is at risk of developing complications of

hypertension Patient requires education regarding

health maintenance.

What conclusion (judgment) does

this patient make?

Patient requires management for his pain

Patient understands the need taking care of health

risks and agrees to work on these aspects

What conclusion (judgment) does

this patient make?

Based on the assessment following nursing diagnoses were

formulated, i.e. the clinical judgment about the patients

actual and potential problems.

Nursing diagnosis

The data collected by

assessment are used to make

nursing diagnosis in nursing

process.

Acc. to King in process of

attaining goal, the nurseidentifies the problems,

concerns and disturbances

about which person seek help.

1. Acute pain related to surgical incision2. Risk for infection related to surgical incision3. Risk for constipation related to bed rest, pain

medication and NPO or soft diet

4. Deficient knowledge regarding the treatment andhome care

5. Ineffective health maintenance

P l a n n i n g

After diagnosis, planning for interventions to solve those problems is done. In goal attainment planning is represented

by setting goals and making decisions about and being agreed on the means to achieve goals.

This part of transaction and clients participation is encouraged in making decision on the means to achieve the

goals.

Identifying the goals and planning to achieve these goals (this step is congruent with planning in the traditional

nursing process)


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What goals do I think will serve the

patients best interest?

1. The client will experience improved comfort, as evidenced by:

a decrease in the rating of the pain,

the ability to rest and sleep comfortably

2. The client will be free of infection as evidenced by normal temperature,

normal vital signs.

3.The client will have improved bowel elimination, as evidenced by:

Elimination of stool without straining

4. Client will acquire adequate knowledge regarding the treatment and

home care.

5.Client will attend to health problems promptly

What are the patients goals?

Patients goals are:

Freedom from pain

Rapid healing

Adequate bowel movement

Acquiring adequate knowledge regarding his health problems

Are the patients goals and professional

goals are congruent?Yes

What are the priority goals?

Relief of pain

Freedom from infection Adequate bowel movement

Improvement knowledge aspect of health conditions

Prompt attendance to health problems

What does the patient perceives as the

best way to achieve goals?

Working with the health professionals

Gaining knowledge

Disclosing adequate information regarding health problems

Is the patient willing to work towards the

goals? Yes


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What do I perceive to be the best way to

achieve the goals?

Goal 1:

Assess the characteristics of pain

Administration of prescribed medicine

Monitor the responses to drug therapy

Provide calm, efficient manner that reassures the client and

minimizes anxiety

Provide a comfortable position as per clients requests.

Goal 2:

Monitor vital signs

Administer antibiotics as advised

Use aseptic techniques while changing dressing

Kept the surgical wound site clean

Report surgeon regarding early signs of infection

Goal 3:

Ensure that the client has adequate bulk in diet and adequate

fluid intake

Instruct the client on prevention of straining and avoiding

valsalva maneuvers

Consult treating physician regarding medications.

Goal 4:

Explain the treatment measures to the patient and their benefits

in a simple understandable language.

Explain demonstrate about the home care.

Clarify the doubts of the patient as the patient may present with

some matters of importance.

Repeat the information whenever necessary to reinforce learning.

Goal 5:

Health education given about the following:

Restriction of heavy weight lifting (more than 20kg) for 6 months

Further management which may be necessary

Diet control for his hypertension

Rehabilitation measures to promote better living

For regular examination of the site for recurrence of hernia


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Are the goals short-term or long term? Goals are both short-term and long term

What modifications required based on

mutuality?

Pain is tolerable to the patient and requires no SOS medication

Constipation is not that severe enough to take medication

Other interventions are mutually acceptable.

I m p l e m e n t a t i o n

In nursing process implementation involves the actual activities to achieve the goals.

This step results in transactions being made.

Transactions occur as a result of perceiving the other person and the situation, making judgments about those

perceptions, and taking some actions in response.

Reactions to action lead to transactions that reflect a shared view and commitment

This step reflects implementation in the traditional nursing process

Am I doing what the patient and I have agreed upon? Yes

How am I carrying out the actions? On a mutually acceptable manner in accordance withthe goals set.

When do I carry out the action? According to priority, a few interventions requireimmediate attention.Other interventions are carried out during the period ofhospitalization till 5th April.

Why am I carrying out the action? Patients condition demands nursing car.

Is it reasonable to think that the identified goals will be reached bycarrying out the action?

Yes

E v a l u a t i o n

It involves to finding out weather goals are achieved or not. In Kings description evaluation speaks about attainment of goal and effectiveness of nursing care.

Are my actions helping the patient achieve mutually defined goals? Yes

How well are goals being met? Short-term goals are met before discharge from hospitalLong-term goals are expected to be met, because thepatient is motivated to continue home care.

What actions are not working?

What is patients response to my actions? Patient is satisfied with my actions

Are other factors hindering goal achievement? Patients age is a hindering factor in goal achievementregarding health maintenance.

How should the plan be changed to achieve goals? Health teaching can be modified according todevelopmental stage.Involvement of family member in care of the patient.

R E F E R E N C E S


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1.

Personal systems are individuals, who are regarded as rational, sentient, social beings.Concepts related to the personal system are:Perception a process of organizing, interpreting, and transforming information from sensedata and memory that gives meaning to one's experience, represents one's image of reality,and influences one's behavior.Self a composite of thoughts and feelings that constitute a person's awareness of individual

existence, of who and what he or she is.Growth and development cellular, molecular, and behavioral changes in human beings thatare a function of genetic endowment, meaningful and satisfying experiences, and anenvironment conducive to helping individuals move toward maturity.

1.Body imagea person's perceptions of his or her body.

2.

Timethe duration between the occurrence of one event and the occurrence ofanother event.

3.Spacethe physical area called territory that exists in all directions.

4.Learninggaining knowledge.

Interpersonal systems are composed of two, three, or more individuals interacting in agiven situation. The concepts associated with this system are:

0.Interactionsthe acts of two or more persons in mutual presence; a sequence ofverbal and nonverbal behaviors that are goal directed.

1.Communicationthe vehicle by which human relations are developed andmaintained; encompasses intrapersonal, interpersonal, verbal, and nonverbalcommunication.

2.Transactiona process of interaction in which human beings communicate with theenvironment to achieve goals that are valued; goal-directed human behaviors.

3.

Rolea set of behaviors expected of a person occupying a position in a socialsystem.

4.Stressa dynamic state whereby a human being interacts with the environment tomaintain balance for growth, development, and performance, involving an exchange

of energy and information between the person and the environment for regulationand control of stressors.

5.Copinga way of dealing with stress.

Social systems are organized boundary systems of social roles, behaviors, and practices

developed to maintain values and the mechanisms to regulate the practices and roles. Theconcepts related to social systems are:

0.Implications for Nursing PracticeNursing practice is directed toward helping individuals maintain their health so theycan function in their roles. King's practice methodology, which is the essence of the

Theory of Goal Attainment, is called the Interaction-Transaction Process.

1.

Assessment phase1. Perception The nurse and the client meet in some nursing situation and perceive

each other. Accuracy of perception will depend upon verifying the nurse's inferenceswith the client. The nurse can use the Goal-Oriented Nursing Record (GONR)throughout the assessment phase.

2. JudgmentThe nurse and the client make mental judgments about the other.3. Action The nurse and the client take some mental action.4. Reaction The nurse and the client mentally react to each one's perceptions of the

other.

Disturbanceis the diagnosis phase of the interaction-transaction process. The nurse and the


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client communicate and interact, and the nurse identifies the client's concerns, problems, anddisturbances in health. The nurse conducts a nursing history to determine the client's activitiesof daily living, using the Criterion-Referenced Measure of Goal Attainment Tool (CRMGAT);roles; environmental stressors; perceptions; and values, learning needs, and goals. The nurserecords the data from the nursing history on the GONR, the medical history and physicalexamination data, results of laboratory tests and x-ray examination, and information gatheredfrom other health professionals and the client's family members on the GONR. The nurse also

records diagnoses on the GONR.

Planning phaseMutual Goal Setting The nurse and the client interact purposefully to setmutually agreed on goals. The nurse interacts with family members if the client cannotverbally participate in goal setting. Mutual goal setting is based on the nurse's assessment ofthe client's concerns, problems, and disturbances in health; the nurse's and client'sperceptions of the interference; and the nurse's sharing of information with the client and his

or her family to help the client attain the goals identified. The nurse records the goals on theGONR.

0. Exploration of Means to Achieve Goals The nurse and the client interact purposefullyto explore the means to achieve the mutually set goals.

1. Agreement on Means to Achieve Goals The nurse and the client interact purposefullyto agree on the means to achieve the mutually set goals. The nurse records the

nursing orders with regard to the means to achieve goals on the GONR.

Transactionis the implementation phase of the interaction-transaction process. Transactionrefers to the valuational components of the interaction. The nurse and the client carry out themeasures agreed upon to achieve the mutually set goals. The nurse can use the GONR flowsheet and progress notes to record the implementation of measures used to achieve goals.

Attainment of goalsis the evaluation phase of the interaction-transaction process. The nurseand the client identify the outcome of the interaction-transaction process. The outcome isexpressed in terms of the client's state of health, or ability to function in social roles. Thenurse and the client make a decision with regard to whether the goal was attained and, ifnecessary, determine why the goal was not attained. The nurse can use the CRMGAT to recordthe outcome and the GONR to record the discharge summary.

Implications for Nursing EducationKing's Conceptual System and the theory of goal attainment lead to a focus on the dynamic interaction

of the nurse-client dyad. This focus, in turn, leads to emphasis on nursing student behavior as well asclient behavior. The concepts related to the personal, interpersonal, and social systems serve as thetheoretical content for nursing courses in associate degree, baccalaureate, and master's nursingprograms. The theoretical knowledge is used by students in learning experiences involving concretenursing situations.

References

King, I. M. (1981).A theory for nursing. Systems, concepts, process. New York: Wiley.[Reissued 1990. Albany, NY: Delmar.]

King, I. M. (1986). Curriculum and instruction in nursing. Norwalk, CT: Appleton-Century-Crofts.

King, I.M. (1992). King's theory of goal attainment. Nursing Science Quarterly, 5, 1926. King, I.M. (2006). Part One: Imogene M. Kings theory of goal attainment. In M.E.

Parker, Nursing theories and nursing practice (2nd ed., pp. 235-243). Philadelphia: F.A. Davis.

IMOGENE KING'S CONCEPTUAL SYSTEM has been found in Taber's Medical Dictionary,

the world's best-selling health dictionary with more than 60,000 terms.

To find other Taber's Medical Dictionary topics,

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Communication and Human Relation in Nursing (2)

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