Comparative Analysis of King’s and Orem’s Nursing Theories

Introduction

Imogene King’s nursing theory, the framework of which was developed in the 1960s, is focused on goal attainment. The current theory itself came into full form in 1981, and it has elements that can very well be implied in the current era, modern ways of nursing practice. King, much like many other baby boomer nursing theory pioneers who we encounter in this course, have contributed tremendously in shaping the future of the nursing practitioners, including the ones who are currently studying to become nurses soon. The theory, which has stood the test of time, is still very relatable because of the focus on the goal-seeking framework, which remains a common factor for anyone with a firm professional objective.

McQueen, Cockroft, and Mullins, in their article, “Imogene King’s theory of goal attainment and the millennial nurse: An important mentoring tool for nurse educators” (2017), talk about how the three interactive systems help the theory to remain applicable in the current context. The three interactive systems, as they identify, are, “individual or personal systems, group or interpersonal systems, and society or social systems” (McQueen et al., 2017). They continue, “The concepts for the personal system are perception, self, growth and development, body image, space, and time. The concepts for the interpersonal are interaction, communication, transaction, role, and stress. The concepts for the social system are organizational, authority, power, status, and decision-making” (McQueen et al., 2017).

Since King’s theory focuses more on the goals of the person and is considerate of customizing the preferences and priorities, it is a good way to incorporate it in the contemporary context. The other theory in the current reading lists of the nursing students that focuses on the person in practice and has stood the test of time equally well would be Orem’s Self-Care theory. It is a theory of a rather grander proposition and it focuses on one of the key factors in health care: the patients’ desires to take care of themselves, as a priority. As Khademian, Kazemi Ara and Gholamzadeh, in their article, “The effect of self-care education based on Orem’s nursing theory on quality of life and self-efficacy in patients with hypertension: A quasi-experimental study” (2020), mention, “self-care is considered as activities that people engage in to maintain, restore or improve their health” and how Orem defined, “three nursing systems including wholly compensatory, partially compensatory, and supportive-educative systems” (Khademian et al., 2020).

While King’s theory has a focus on the societal and communal impact on one’s health, Orem has a focus on the personal perspective on self-care. The theories can be put face-to-face for their interpersonal vs. intrapersonal appeals in self-care. This paper, thus, compares Imogene King’s theory to Orem’s, to identify how both theories can be implemented side-by-side to educate the nurses of the contemporary practices in a more holistic approach to the challenges as professionals they might come across in the unpredictable nature of the job itself.

Malekzadeh, Amouzeshi and Mozlam, in their 2018 study, examine how Orem’s theory affects nursing students’ clinical performance, and they identify how, “Teaching Orem’s self‐care model could improve students’ caring skills” (Malekzadeh et al., 2018). This paper, however, focuses on King’s theory primarily and attempts to identify how teaching the theory, in collaboration with Orem’s, might improve the students’ ability to communicate with the patients better, with a developed sense of care and attention.

a. Patient-Centered Care

Imogene King’s theory of goal attainment identified the immense importance of the nurse-patient relationship to achieve a plan of care that would enable compliance to achieve the said goal(s). This is done by sharing information between the nurse and patient that not only relates to the current health issues/concerns but also the patient’s systems to identify specific goals. King’s theory states that three systems interact in the Theory of Goal Attainment. Gonzalo identifies, “These are the personal system, the interpersonal system, and the social system” (Gonzalo, 2019). This means that to truly provide patient-centered care, the nurse needs to become aware of all three systems and how they uniquely relate to their patient and use this information for the goal identification process.

For the personal system the nurse must gain an understanding of what the patient thinks of oneself; in other words, their existence, concept of who they are, fluctuations of body image, commitments and values. Interpersonal systems require the understanding of the connections the person has, how they interact with others, their communication skills, roles they play and roles others play in their lives. Lastly, their social systems are equally as important since these include education, healthcare, and religion. All of which have an influence on the behaviour of the person and could either aide in the process of goal attainment or hinder it.

By using King’s theory, we will know the patient more personally and be able to apply their specific needs regarding all three systems and use it to develop their healthcare goals. The plan of care will be catered precisely for this patient making it uniquely adequate for goal attainment. The goals are set mutually by the nurse and patient, as Gonzalo explains, “The theory explains that assessment takes place during interaction…During this phase, the nurse gathers data about the patient including his or her growth and development, the perception of self, and current health status” (Gonzalo, 2019). The use of proper communication is of utmost importance to identify any inaccuracies in the information gathered before developing the nursing diagnosis, plan of care, implementation, goals and time frame. During follow-ups, the nurse will once again interact, communicate and assess using all three systems to evaluate goal achievement.

b. Teamwork Collaboration

Dorothea Orem was one of the prime nursing theorists, she published her first theory in 1959, which enabled her to win many awards from different societies. In 2017, Naz states that Orem’s first published theory has been revised multiple times and has now been updated to tackle different general concepts, such as self-care, self-care agency, therapeutic self-care demand, and self-care requisites. For example, in terms of self-care, Orem expressed in Naz’s (2017) published article, that there are three main self-care requisites, like Universal self-care requisites (I.e. air, wind, food, elimination, etc.), Developmental self-care requisites (I.e. adherence to medical management, awareness of potential problem associated with the regimen, etc.), and Health deviant self-care requisites (i.e. maintenance of the developmental environment, and threat prevention of normal development).

Naz (2017) states that Orem’s theory focused on the importance of how one needs to care for themselves leading to faster recovery and independence. Orem’s Self-Care Deficit Theory describes that a nurse is needed when a person has become dependent and lost the inability to care for himself. The theory enumerates five methods of assisting a dependent person and they are: doing or acting for another, supervising others, supporting others, offering an environment that promotes personal development about meeting future needs, and educating others (Naz, 2017). With that said, the use of Orem’s Self Care Deficit, not only benefits the patient’s well –being but also creates a great patient-nurse relationship because this will “help students to understand their problems more deeply and provide better care for them” (Malekzadeh et al. 2018). As a result, this leads to lower healthcare costs, increased in quality development, and better patient outcomes (Malekzadeh et al. 2018).

A great example of the use of Orem’s Self Care Deficit Theory in nursing practice can be seen in how it impacts the lives of patients with Type II Diabetes in Ilam, Israel. Borji, Otaghi, & Kazembeigi (2017) states that self-care is important in patients suffering from diabetes because it is crucial in the control and treatment of the disease, for instance, “self-monitoring of blood glucose, diet, setting insulin dosage, and doing regular physical activity.” With that said, Ghafourifard & Ebrahimi (2015) surveyed 20 diabetic patients, in which the surveyors educated the patients on how to care for themselves using Orem’s theory, and the results showed that there was an increase in self-satisfaction amongst the five patient domains, which are: diet, physical activity, blood sugar levels, medication therapy and diabetic foot education.

In 1968, Imogene King introduced her Theory of Goal Attainment (TGA) and she describes that “each human is an open system with unique needs, motivations, and wants which are different from those of other humans (Adib-Hajbagher & Tahmouresi, 2018). Also, King states that TGA focuses on a patient as a system that includes, self-perception, growth and development, body image, personal space, learning and comping furthermore, establishing better interaction between patient and environment. Like Orem, King also finds importance in maintaining a good patient-nurse relationship, especially in the “identification of problems, health disorders, their perception of problems and sharing information to plan strategies to reach the goals proposed by agreement” (Araujo et al., 2018).

Araujo et al. (2018) published a study in which they explored the effectiveness of nursing interventions based on Imogene King’s theory of Goal Attainment (TGA) and if it will result in better care for diabetic patients and increase adherence to treatment. The study focused on different goals to achieve better blood sugar levels, for instance, some of the goals were the use of sweeteners and/or removing sugar from the diet, start/restart physical activity, medication adherence, decrease in carbohydrate consumption, reduction of glycemic lab values, weight loss, increase fruit intake, etc. Nurses helped patients choose goals that they can realistically achieve, which were then reassessed every visit. Also, if the patient was not able to reach the set goal, he or she and the nurse will reevaluate and explore ways on how to achieve the goals. Once the study was done, the authors reported that The Goal of Attainment aid in the accomplishment of the stated goals because it “…promoted positive surveillance, due to the greater interaction of both, it was possible to better adapt the strategies of adherence” (Araujo et al., 2018).

Based on the statements above, it is evident that the use of nursing theories in the nursing practice is important not only for the patients but also for the nursing team because it gives provides better care for patients, relationships and adherence to care.

c. Evidence-Based Practice

According to Alligood (2017), “[t]he primary source for Orem’s ideas about nursing was her experiences in nursing. Through reflection on nursing practice situations, she was able to identify the proper object, or focus, of nursing.” In Orem’s theory, “view of person-as-agent is central” to the self-care deficit theory. Another important component in Orem’s theory to note is that the assumptions that were made “rest upon the implicit assumption that human beings have free will.” The foundation of Orem’s work is that of “the view of human beings as [a] person reflects the philosophical position of moderate realism” (Alligood, 2017). Orem placed a lot of emphasis on the individual and the ability of that individual to shape his/her path to recovery. Orem’s theory has been adopted by the rehabilitation component of health and healing. This is in part due to the nature of it being focused on the patient’s abilities and what the patient brings to their recovery. Orem theorized that the patient could contribute the most to their recovery and the greater the effort the better the outcome. Orem’s focus on the patients and their abilities encouraged self-care as much as physically possible (Petiprin, 2016).

In comparison, King’s works foundation is rooted in answering the question of what the goal of nursing is. King’s focus was on the nurse-patient relationship. She was able to achieve this through research. King developed “a documentation system, the goal-oriented nursing record” which she used to record goals and outcomes. This data collection incorporated evidence-based practice in her theory development by utilizing both qualitative and quantitative research modalities. The relation between the practitioner and the patient is the main driving factor behind this theory. Meaningful interaction and communication within this relationship aids in the development of a patient centered plan of care. The nurse can offer knowledge and expertise in the field and the patient can offer unique and specific details that can mold the plan of care resulting in an individualized approach. This could not be achieved if not for the foundation that is built once the relationship is initiated. King was able to incorporate the use of the nursing process into her theory.

This is important to note since the nursing process was developed in 1958 which guides nursing practice in all aspects today. By utilizing the five steps of the nursing process “assessment, diagnosis, planning, implementation, and evaluation” the nurse can obtain the information that is used as the basis surrounding patient centered care which all areas of healthcare have adopted in one form or another (Toney-Butler, 2019). Therefore, evidence-based practice can be identified throughout King’s work since she relied heavily on the use of the nursing process. With all of this in mind, Toney- Butler & Thayer (2019) believe that “nurses are in a position to promote change and impact patient delivery care models” now and in the future as healthcare is an ever-evolving system.

d. Quality Improvement

The purpose of QI or Quality Improvement projects is to test the effectiveness of the nursing theories in clinical practice and to improve patient care goals. The Orem self- care model focuses on self-care which includes activities that human identifies and carry out for their own sake to maintain their life and health and have a constant feeling of wellbeing.  Orem’s Self Care Model is a suitable clinical guideline for planning and implementing the principles of self-care and is used as a conceptual framework to guide self-care programs.

The Self-care model is designed in three types of care systems based on patient’s needs and conditions in health-deviation and the role of the nurse: Wholly compensatory nursing system, partly compensatory nursing system, and supportive-educative nursing system. In this model when the patient is ready to learn and perform the behavior but cannot do it without help, the supportive-educative nursing system is used. Here, the nurse’s role is to give further advice. This system contributes to decision making, behavior management and acquisition of knowledge and skills.

King’s Theory focuses on nurses can help define a clinical quality problem by; the nurse must know that communication is the key and trust between patient and nurse is most important. Imogene King’s theory of goal of attainment describes a dynamic, interpersonal relationship in which a patient grows and develops to attain certain life goals. The model focuses on the attainment of certain life goals. It explains that the nurse and patient go together in communicating information, set goals together, and then take actions to achieve these goals. The factors that affect the attainment of goals are roles, stress, space, and time.

The nurses’ goal is to help patients maintain health so that the patient can function in their roles. The nurses function in interpreting information in the nursing process, to plan, implement and evaluate nursing care. The essence of her theory is that the nurse and the patient come together, communicate, and make transactions – they set goals and work to achieve the goals they set.  King believed that the goal of nursing is to help individuals maintain their health so that they can function in their roles and transactions occur to set goals related to the health of the patient.

e. Safety

As already established in this group paper, both theories strive for the same outcome: the health of the patient and/or the recovery of the sick patient to good health. However, King and Orem stress different approaches to the patient-nurse relationship to achieve the same result.

Imogene King’s theory of Goal Attainment relies on the nurse-patient relationship to determine the best goal for the patient and the best method to reach it. King believes that the patient and the nurse should work together as a team (De Leon-Demare 2015). In contrast, Orem’s theory stresses that patient self-care is essential for health and recuperation from illness. The nurse’s role for Orem is to facilitate this self-care. Self-care can be learned (Younas 2017). However, factors such as age, socioeconomic conditions, and family support among others can help or hinder the patient to accomplish this. This part of the paper tries to illustrate how both theories can be applied to the practice of nursing safety by using GI procedures that we are familiar with.

Orem’s theory is appropriate for prepping the patient for colonoscopy procedures. A skilled nurse will evaluate the patients to see if they can understand how to prep. Then the nurse will tell them what they need to do before showing up for the appointment and tell them why they need to follow instructions. When the patient arrives for the procedure, the nurse continues to prep the patient for a successful procedure. This may involve education about what to expect after the procedure with regards to pain management, being sleepy, and needing a ride home from a responsible adult. In other words, the nurse enables the patient to self-care before the procedure and afterwards too.

During the actual colonoscopy procedure, things change. King’s theory becomes more appropriate. The nurse explains to the patient what the next steps will be. But the nurse is the one who performs the next steps. The patients do not insert their own IVs. They do not give themselves medication. The nurse communicates what she or he is doing to the patient and asks how the patient feels, but it is the nurse that is doing the work. The self-care is suspended until the patient goes home. Once the patient is home the patient resumes self-care according to the Orem model.

This illustrates is why Goal attainment theory and Self-care theory can be considered complementary theories. Using both theories to care for GI patients who are having colonoscopies ensures a safe outcome for the patient. Nurses need to understand that Orem is correct. Patients have the right and the responsibility to take care of themselves. But King is also correct. Sometimes the nurse must assume responsibility. But this must be done in communication with the patient. King is also right; the nurse and the patient must work as a team so that the end goal of a safe return home post-procedure is met.

f. Informatics

Informatics application comparison between Imogene King and Orem’s nursing theory. Due to the high demand of our modern world, we need to equip our healthcare with up to date technology that can provide healthcare systems using a wide process of information and data and fast communication. With the new healthcare system evolving it is capable of immediate gain to healthcare information, knowledge, and data for healthcare workers including nurses in culturally diverse and complex world. Nursing informatics is a combination of information science, nursing science, and computer sciences that are meant to assist the processing and management of nursing information, data, and knowledge. Nursing informatics gains information through the nursing theory by King. For example, the computerized information system tool can help nurses in educating patients just like a medical practitioner doing Telehealth.

The current barriers to using nursing knowledge are insufficient classifications and terminologies in computerized information systems for healthcare systems. The classification of nursing systems can be designed to enable access to information, knowledge, and data that nurses can use to set goals for the culturally diverse and complex world. The data element in the structure can be added to the records of patients to document vital nursing interventions. The activities, labels, and definitions will help in planning towards the process of setting goals, recommend the important changes in a plan of treatment, make desirable goals and discuss the progress of goals attainment. Nurses can find applying these concepts useful in their nursing process especially in using technology to document their interventions within the computerized healthcare records.

Orem’s theory highlights the importance of patient-nurse interactions, and the technology must not replace the nurse, as to the physical presence and support of patients by the nurse is the main factor that can lead to their recovery. Health information technology (HIT) interventions have great potential for engaging hospitalized patients in their care but there is a greater need for enhanced and better interdisciplinary collaboration between health and IT researchers for effective design and evaluation of HIT interventions. (Roberts, S. et.al. 2017).

Orem still recommends the use of technology even if high utilization of nursing informatics technology, to help nurses have their patients recover quickly. Since in this theory, Orem defines the nursing process as a process system. To better makes the process easier in nursing practice, nurses need aid from technology. Nurses may use social technologies, which focus on human needs, communication, and limitations. However, these should not take the place of the nurse, and the special role they play in the nursing process.

Conclusion

There are different factors to consider when setting the appropriate goals which make it a complicated issue. King’s theory indicates that it is the nurse’s responsibility to interact with individuals and groups to identify the complicated and specific needs of each they encounter in a nursing situation. Another side of King’s theory is that nurses need to acknowledge the differences between patients, feelings, attitudes, customs, and beliefs. The differences are in existence because of pain, food, sleep, death, birth, body image, power, status, authority and separation from a family which all help to contribute to identifying the patient’s goals and needs. By embracing healthcare informatics and technology, understanding their strengths and weaknesses and using them to help clinical decision making, healthcare providers can stay ahead of the curve and help advance their practice and patient safety (Quinn,  2017).

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