Viewpoint: Use of King’s Conceptual System, Nursing Informatics, and Nursing Classification Systems for Global Communication
Killeen, Mary B
PURPOSE. To propose a common nursing language for communication among members of the nursing community worldwide.
DATA SOURCES. The Taxonomy of Nursing Practice, nursing informatics literature, King’s Theory of Goal Attainment applied to the nursing process.
DATA SYNTHESIS. Several milestones in nursing in the 20th century indicated the need for a universal language for nursing. The nursing process provides a method for synthesis of nursing data, information, and knowledge and is congruent with Imogene King’s Theory of Goal Attainment.
CONCLUSIONS. The authors advocate for a common nursing language (nursing classification and terminology systems) that would unify nurses worldwide. Supported by nursing theory and technology, global communication would be enhanced for nurses and the interdisciplinary teams of which they are a part.
IMPLICATIONS FOR PRACTICE. Use of Imogene King’s Conceptual System and Theory of Goal Attainment and the nursing specialty of Nursing Informatics are examples of nursing theory and technology to frame global communication.
Search terms: Imogene King, nursing classification systems, nursing informatics, nursing terminologies, nursing theory
Every day we are reminded that we live in a world of constant change, influenced by instant communication about global events. Instant communication represents an information processing world of systems. Systems have been designed to provide access to data, information, and knowledge for use by nurses in a complex and culturally diverse world. King’s (1996) definition of systems fits with our 2007 global context: “A system is defined as a series of functional components connected by communication links exhibiting purposeful, goal directed behavior” (p. 61). In a shrinking world, the need to develop a universal language for nurses to cope with communication in an information processing world of systems is evident. A common language among nurses worldwide would describe the categories of various systems wherever they occur.
Theory informs a discipline and helps define the discipline’s boundaries. Theory shapes how we define a problem. Research is done to test solutions to problems. Once results of research are identified, they can be applied to practice. Technology is a means of achieving a purpose such as evidence-based practice. Currently there is little theory in use related to nursing technology in the form of nursing informatics research and nursing language classifications. This article explores how King’s transaction process in her theory of goal attainment is useful for coping with a world of systems ruled by technology. Nursing informatics and nursing terminologies and classification systems such as NANDA (NANDA International, 2005), Nursing Outcomes Classification (NOC; Moorhead, Johnson, & Maas, 2004), and Nursing Interventions Classification (NIC; Dochterman & Bulechek, 2004) can benefit from use of nursing theory in order to apply research to practice. The purpose of the authors’ viewpoint is to propose a blending of nursing informatics and nursing theory for improved use of technology to facilitate global communication among the nursing community.
Major Milestones in Nursing
Interconnections among historically significant milestones in nursing help us understand evidence-based practice in the 21st century. In the last half of the 20th century the diverse phenomena encountered by nurses in the complex world of nursing practice required a scientific approach to identify basic knowledge for nursing. The nursing process first proposed by Yura and Walsh (1983) in the late 1960s provided a systematic method to organize patient information to assess, plan, implement, and evaluate nursing care. Three major milestones in the years that followed were interconnected with the development of nursing knowledge for use in practice: the development and use of conceptual systems and theories during the scientific evolution of nursing in the 1970s, classification systems beginning in the 1980s, and nursing informatics applications in the 1990s. Each milestone is related to the other by the potential of a common language to speak about the phenomena of nursing in a technologic environment. The interconnections between these three milestones are similar to the interconnections between structure, process, and outcomes as elements for nursing’s use of technology in healthcare systems.
King’s Conceptual System as Structure for Technology Use
Structure provides an organized approach to demonstrate the relationship of multiple factors in an organization. Scientists who have been studying systems have noted that the only way to study human beings’ communication and interaction with the environment is to design a conceptual framework of interdependent variables and interrelated concepts.
King’s Conceptual System (1981, 2001) provides one approach to structure a world community. King proposed a structure of three interrelated systems and concepts that define the physical and social environments within which human beings function (Figure 1).
Personal systems represent individual human beings. Selected concepts identified as relevant for understanding human beings as persons are perception, self, growth and development, time, and personal space. Individuals form groups that create another kind of human experience called interpersonal systems made up of dyads (two individuals, e.g., nurse and patient), triads (three individuals), and small groups. Selected concepts that help one understand human-environment interactions are role, communication, interaction, transaction, and stress. Large groups with common interests and goals create another kind of human experience within a community organization called social systems. A few examples are family systems, education systems, religious systems, and healthcare systems. Selected concepts are organization, authority, power, status, and decisions. Age is a critical variable in all three systems.
The three systems that make up King’s conceptual structure represent interconnected links for communication of information in a high-tech world of health care and nursing. The common focus and unifying aspect is human beings interacting in various social and physical environments (Frey & Sieloff, 1995). As individuals we are born, grow, and develop within the social context of each country. A sense of global community can be understood as we view communicative interactions of individuals and groups with linguistic, ethnic, and religious differences. The conceptual system in Figure 1 provides an organized approach to demonstrate the relationship of multiple factors in a system beginning with interactions of human beings in specific environments.
Ten concepts (self, role, perception, communication, interaction, transaction, growth and development, stress, personal space, and time) were selected by King from her conceptual system to develop a Theory of Goal Attainment (1981). These concepts are relevant today to the global issues of cultural diversity and transcultural nursing (Hustling, 1997). A Transaction Process Model (Figure 2) was designed within the Goal Attainment Theory as a fundamental interaction process that facilitates ordered function so human groups can communicate as systems in societies and nations.
The Theory of Goal Attainment and the Transaction Process were developed as part of the scientific movement in nursing. However, because it is a general systems theory, the knowledge can be used in any system that encompasses individual human beings interacting in any situation to achieve goals.
An example of the usefulness of King’s conceptual system as structure in technology use is the emphasis on interdisciplinary teams. The delivery of healthcare services requires both an individual (personal system per King) and interdisciplinary team (a type of interpersonal system per King) approach to the delivery of quality care to individuals. Imperative in the team approach is the establishment and maintenance of professional relationships that include open communication among members of the team and mutual respect for one’s ability to contribute to the total plan of care resulting in goal attainment and outcomes. The Transaction Process in King’s theory when used in interdisciplinary teams facilitates mutual goal-setting with patients based on each member of the team’s specific knowledge and functions. This often facilitates role congruence and respect for the knowledge, skills, and values each member brings to the situation.
Nursing Informatics as Structure for Technology Use
Nursing informatics was designated as a specialty by the American Nurses’ Association (ANA) in 1992. Nursing informatics is defined as a “combination of computer science, information science, and nursing science designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and delivery of nursing care” (Graves & Corcoran, 1989, p. 227). Informatics nurses are specialists in managing healthcare information technology. Information is the communication or reception of knowledge. Currently, nursing informatics knowledge is not based on theory to any great degree. Consequently, nursing informatics is not using nursing’s knowledge as it should. For example, there are few tools in computerized information systems to help nurses educate patients. One barrier to use of nursing knowledge in practice is lack of nursing terminologies or classifications in computerized information systems in healthcare organizations.
Nursing classification systems have been designed to provide access to data, information, and knowledge for use by nurses in a complex and culturally diverse world. Data provide a basis for specific information that describe phenomena in nursing. Knowledge is a synthesis of information that identifies relationships of distinct phenomena in nursing. Knowledge deals with relationships that connect the elements of data and result in decisions. Classification systems help nurses group similar ideas and concepts that are fundamental in organizing and communicating information data for use in nursing practice.
The nursing classifications systems that have been developed and recognized by the ANA in the United States must be clinically useful for making diagnostic, intervention, or outcome decisions. ANA’s Nursing Information and Data Set Evaluation Center (NIDSEC) requires a relationship between the design, development, and implementation of clinical practice databases and the ANA’s Nursing: Scope and Standards for Practice (2004). There are currently 13 ANA-recognized nursing terminologies/classifications that support nursing practice (ANA, 2005). The ANA list includes several classifications for nursing communication using the nursing process: Home Health Care Classification (HHCD), NANDA International, Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), Omaha System, Patient Care Data Set (PCDS), and the Perioperative Nursing Data Set (PNDS). In addition, the International Council of Nurses (ICN) has developed and tested a nursing classification system for worldwide use: the International Classification of Nursing Practice (ICNP).
An example of the usefulness of nursing informatics as structure in technology use is one NIC label: Multidisciplinary Care Conference (Dochterman & Bulechek, 2004). With the code of 8020, this data element can be added to the patient’s record as documentation of a critical nursing intervention. The label, definition, and activities of Multidisciplinary Care Conference are captured for use worldwide in the same way and mean the same thing. Parts of King’s Transaction Process are captured in the NIC activities, i.e., discuss progress toward goals, establish mutually agreeable goals, and recommend changes in treatment plan, as necessary.
The Nursing Process as Process for Technology Use
Process is a dynamic function of systems. One approach to technology is to select a process that is theoretically based and related to the nursing process of Yura and Walsh (1983), which is a standard method used internationally by nurses (Figure 3). The nursing process is used to record the direct care work of nurses in all types of settings. This method includes assessment of the patient for information from which nurses make a nursing diagnosis, establish expected outcomes and select planned interventions, implement the plan, and evaluate the actual outcomes. The nursing process is a system of cognitive, affective, and behavioral activities by the nurse and is based on knowledge that is organized in taxonomies of nursing knowledge, i.e., nursing classifications. The relationship of the nursing process as method and the nursing process as theory, i.e., King’s Transaction Process, is shown in Figure 3.
The concepts in the Transaction Process provide theoretical knowledge to implement the nursing process method and describe the nature of the nursepatient interactions that lead to achievement of goals. A critical variable in this process is mutual goal-setting.
Another relevant concept when using the nursing process is perception, which is a process of human transaction with the environment. Perception is “a process of organizing, interpreting, and transforming information from sense data and memory” (King, 1981, p. 24). Perception gives meaning to one’s experiences, represents one’s image of reality, and influences one’s behavior. It is essential for nurses to have knowledge of perception if they are to assess, interpret, and plan for a patient’s identification and achievement of goals that maintain health. The perception concept is essential in understanding persons as systems and the influence perceptions have on communication and human interactions. It is a basic concept in the transaction process that leads to goal attainment and outcomes. Perception is a critical concept for nurses because it is the basis for gathering and interpreting information. Hustling (1997) noted that “perception or expectations and communication have roots in cultures and past experiences” (p. 16).
The behavior of individuals has been described as human acts. When two individuals meet in any situation, some kind of action is involved. The nursing act is like all other human acts, that is, a sequence of behaviors in the nursing process. Observations of nursing acts indicate that the perceptions and judgments of individuals are involved in every type of interaction. Since perception, judgments, mental actions, and reactions are not directly observable; inferences are made about these components of human behavior. Nursing acts are directed toward health and can be observed as a process of interaction between nurses and patients in specific situations. They may be influenced by the situation and by interactions with family, physicians, and other persons and events. The nursing process that has become the standard method used in nursing situations identifies and explains some of the essential functions performed by nurses-assessment of the client’s health status, formulation of a plan on the basis of the information gathered, implementation of a plan of action, and evaluation of its effectiveness.
An example of the usefulness of the nursing process as process in technology use is the documentation of the nursing process in the computerized healthcare record. Information technology has enabled healthcare organizations to function as integrated healthcare delivery networks, improve quality, and become socially and environmentally responsive (Davenport, Jarvenpaa, & Beers, 1996; Tapscott & Gaston, 1993). Nursing data must be included in computerized information systems in organizations or nursing’s work is invisible. Much broader than “steps,” the nursing process is an international method to use the discipline’s body of knowledge organized in the structure of theory and nursing classifications.
Outcome and Evidence-Based Practice
The interrelationship of process and outcome are the focus of nursing and health care. Process is a dynamic function of systems. Outcomes are the results of process. The term “outcome” assumes a process is central in providing information to evaluate effective nursing care. Outcome is defined as a change in a patient’s health status. Outcomes are patient-centered, goal-oriented, realistic, and measurable. Outcomes provide data that determine evidence-based practice. The delivery of quality care in healthcare systems is expected by the public. One measure of quality is a measure of effectiveness of care. Effectiveness of care can be measured by whether or not the goals for health promotion, health maintenance, or recovery from illness have been attained. King’s Theory of Goal Attainment describes the nature of nurse-patient interactions that lead to transactions and achievement of goals. It presents a standard whereby nurses purposefully interact with patients, mutually establish goals, and agree to the means to use to achieve the goals. Mutual goal-setting is based on the nurses’ assessment of patients’ concerns, problems, and disturbances in health. The Theory of Goal Attainment helps nurses organize elements in the process of nurse-patient transactions that result in goals attained, i.e., outcomes. Outcomes provide data for evidence-based practice. The nursing perspective of evidence-based practice includes many concepts initially defined by King (Sieloff, Frey, & Killeen, 2001).
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Mary B. Killeen, PhD, RN, CNAA, BC, and Imogene M. King, EdD, RN, FAAN
Mary B. Killeen, PhD, RN, CNAA, BC, is Assistant Professor
at the Michigan State University College of Nursing, and
Imogene M. King, EdD, RN, FAAN, is Professor Emerita
at the University of South Florida, Tampa, College of
Author contact: email@example.com
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