ENGENDER NANDA Guideline: Ensuring Gender inclusion in NANDA‐I. A Delphi Study

ABSTRACT

Aim

To develop a guideline for the integration of the gender perspective in the use of NANDA‐I nursing diagnoses.

Design

The Delphi technique was used in order to reach consensus between two groups of experts: (a) in nursing diagnoses and (b) in gender, thus allowing us to draw up the guidelines to include the gender perspective in the three levels of the NANDA‐ taxonomy (domains, classes and diagnoses).

Methods

The Delphi study included four rounds. The first was carried out considering a qualitative approach to define the items of the guidelines followed by three Delphi rounds to reach consensus combining quantitative thresholds and qualitative feedback. Thirty experts were invited to participate in order to assess and reach consensus on two main criteria: relevance and feasibility of the items. Consensus was evaluated by calculating the mean and standard deviation of each item according to the scores obtained by the participating experts. The study followed the CREDES Guidelines.

Results

The participants included 20 experts in gender and NANDA‐I nursing diagnoses. The Delphi process yielded 14 indicators, organized into three domains. This process integrates the consideration of differentiating characteristics in terms of sex, the use of non‐sexist language in the diagnosis, the consideration of the gender perspective in the process of clinical reasoning and the need for including gender experts in the process of translating NANDA‐I language into languages that use binary gender nouns.

Patient or Public Contribution

No patient or public involvement occurred in the design or conduct of this study.

Reporting Method

In order to allow critical appraisal of the methodology and resulting guidance, the study followed the CREDES Guidelines, a reporting standard for Conducting and REporting DElphi Studies.

1. Introduction

Health is related to the environment and personal circumstances, such as place of origin, level of education, income or living conditions and, of course, access to and use of health services (Organización Panamericana de la Salud 2013). In this regard, gender, social class and culture determine the existence of inequalities in health‐disease‐care processes. (Braveman 2006).

Accordingly, structural inequities are personal, interpersonal, institutional and systemic drivers, such as racism, sexism, classism, ableism, xenophobia and homophobia that determine the fair distribution of health opportunities and outcomes (Bradley et al. 2016).

In today's globalized societies, gender is understood as a sociocultural construct that imposes specific attributes, behaviours and expectations for men and women that, if not taken into account in health care, cause a gender bias in the physical and mental health of men and women (Gupta et al. 2019).

In reflections on the introduction of gender biases in Nursing, it's important to bear in mind that they may be due to the presumed equality between women and men in the face of clinical manifestations when the evidence shows that this is not the case, or on the contrary, considering differences where they should not exist, as also happens in other fields of clinical care. But in addition, gender biases in nursing care can lead to unequal behaviours by health services and professionals, applying poor, stereotyped treatment and follow‐up options that lead to inequality or are erroneous (Ruiz‐Cantero and Verdú‐Delgado 2004).

To ensure better and higher quality nursing, gender categories must today be considered broadly in clinical practice by integrating gender relations and roles and a perspective that goes beyond binarism (Eliason 2017). The goal should be to provide comprehensive care and ensure that the individual's health needs are met and avoid an essentialist and victimistic vision that perpetuates a narrative that downplays the importance of the agency of women and girls or people with non‐normative identities such as lesbians, gays, bisexuals, trans and intersex people (LGBTI). In addition, current lines of research on the study of the impact of gender on health and care processes establish the requirement of an intersectional approach, which is also based on the theories that laid the foundations of scientific advances from a perspective of feminism and poststructuralist approaches (Coll‐Planas et al. 2023).

In this sense, various studies highlight the positive impact of considering the gender perspective in health care, research, management and education (Hallam et al. 2022; Ruiz‐Cantero and Verdú‐Delgado 2004).

However, studies show that gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research (HSR), gender analysis seeks to understand how gender power relations create inequities in the access to resources, the distribution of labour and roles, social norms and values and decision‐making (Morgan et al. 2018). Also, current nursing interventions and research examine gender in HSR processes by reflecting on how the research process itself is imbued with power relations.

Although a growing body of work clearly documents gender inequalities in health, researchers often fail to adequately integrate gender as part of public health research. Public funding bodies must require researchers to include gender in health research from early on as part of the design and to conduct gendered analysis as part of the overall drive towards the provision of more equitable health systems. Therefore, health equity that incorporates the gender approach must become a priority in the health system (Palmeirim et al. 2023).

In this sense, nursing, a discipline that considers the individual as a biopsychosocial and cultural being, is the profession that can best address the complexity of people's needs and responses this 21st century. To respond to the complexity of the essence of our discipline, nurses deploy our patterns of knowing that constitute the knowledge of our profession (Carper 1978).

Currently, to consider the gender perspective, it is necessary to connect with the emancipatory pattern of knowing (Chinn et al. 2021). This way of knowing acknowledges the social, political and cultural influences on health and caring. This understanding requires one to critically analyse power dynamics and health inequities, and perhaps most importantly, in the nursing praxis, it requires reflective action towards social change.

Lunney (2010) states that words are needed to describe human responses because human beings think with words. Thus, standardized nursing languages describe nursing care, allow comparing data for research and consequently develop appropriate health policies for the social demands of the moment. Focusing on the NANDA‐I taxonomy, this constitutes a system of nomenclature and organization of nursing diagnoses that allows us to describe human responses to different health and life situations (Herdman et al. 2024), which at present must inevitably consider the gender perspective in the description of these responses and behaviors.

Some of the areas included in the NANDA‐I domains have been studied from a gender perspective identifying health inequities in women caused by these sometimes‐learned responses. Thus, several studies have concluded that the greater perception of deterioration in the health of female caregivers compared to male caregivers is related to the fact that women are subject to a greater perception of responsibility in caregiving and to the more intense characteristics of the care provided by women (Swinkels et al. 2017; Mosquera Metcalfe et al. 2019 and Vafaei et al. 2016). The study concludes that women adopt different lifestyles from men due to their socially established role. In addition, one study concludes that the individual experiences and narratives collected in the defining characteristics (DC) and related factors (RF) of nursing diagnoses allow us to deepen our understanding of the impact of gender imposition on individual health responses (García Calvente and Marcos Marcos 2011).

In this sense, a previous work which systematically described and analysed the gender perspective in the use of the diagnoses contained in the NANDA‐I classification in observational studies concluded that the gender perspective is not systematically incorporated in the use of the NANDA‐I classification (Rifà‐Ros et al. 2023). The failure to incorporate this gender approach can erroneously lead to the design of care plans with inadequate responses that are not adapted to the realities of the health determinants of women.

To prevent interventions not meeting the needs of societies, several guides exist to promote conducting research and interventions from a gendered perspective (Jenkins and MD 2020; Van Epps et al. 2022). However, such guides do not exist in relation to the use of the NANDA‐I taxonomy.

Therefore, to move forward, considering the evidence on the existence of gender biases in the use of the NANDA‐I classification, it is necessary to identify the specific aspects that must be considered in order to analyse each of its diagnoses integrating a comprehensive gender approach that includes gender relations and roles with a perspective beyond binarism. Accordingly, the aim of this study is to develop the “ENGENDER” NANDA Guideline (ENsuring GENDER inclusion in NANDA‐I) to integrate a gender perspective in the use of NANDA‐I nursing diagnoses.

2. Methods

2.1. Design

The Delphi technique was used in order to reach consensus between two groups of experts: (a) experts in nursing diagnoses and (b) experts in gender, thus allowing to draw up the guidelines to include the gender perspective in the three levels of the NANDA‐I taxonomy (domains, classes and diagnoses). In order to allow critical appraisal of the methodology and resulting guidance, this study followed the CREDES Guidelines, a reporting standard for Conducting and REporting DElphi Studies (Jünger et al. 2017).

2.1.1. Study Participants

The Delphi panel consisted of a purposive sample of experts in gender and NANDA‐I nursing diagnoses with academic and clinical backgrounds. In terms of academic expertise, the participants had a minimum of two peer‐reviewed publications on nursing diagnoses or gender in the past 5 years; in terms of clinical expertise, the experts had at least 5 years' experience in the same field of practice.

The identification and recruitment process differed according to the experts' profile. Gender experts were identified through their research publications and their roles as gender coordinators at various Spanish universities; additionally, a snowball sampling technique was used as some experts facilitated contact with other peers sharing the same profile. Regarding NANDA‐I experts, we contacted NANDA‐I Committees, who proposed several candidates. Furthermore, we reached out to faculty members from various universities who had served on the committees of ACENDIO (Association for Common European Nursing Diagnoses, Interventions and Outcomes) and AENTDE (Asociación Española de Nomenclatura, Taxonomía y Diagnósticos de Enfermería), all of whom are internationally recognized professionals in the field of standardized nursing languages.

Exclusion criteria have not been established. In order to establish a representative sample, the criteria established by Humphrey‐Murto et al. (2017), have been followed. It affirms that stability is achieved when participants range from 6 to 12 across different disciplines. Considering a 30% rejection rate, 30 experts were invited to participate in the study and were contacted by the different project partners. Twenty agreed to participate.

2.1.2. Study Procedure

The study comprised four sequential rounds. The first round followed a qualitative approach and was used to define the items of the guideline; therefore, it was not considered a formal Delphi round. This was followed by three quantitative Delphi rounds aimed at assessing the level of participant agreement with the variables categorized for gender analysis.

Data from all rounds were collected using a Google Forms questionnaire and exported to an Excel spreadsheet for analysis. Participants' sociodemographic characteristics were recorded in each phase, including gender, age, years of experience in the field of diagnosis or gender, country of citizenship, level of education, field of study and professional field.

The number of experts who responded was maintained across all four rounds.

2.1.2.1. Construction of Gender Perspective Indicators: Preliminary e‐Round and Critical Analysis

To develop the first set of elements for the proposed guideline, the results of a previously conducted systematic review were taken into consideration (Rifà‐Ros et al. 2023), which found that gender perspective is not systematically incorporated in the use of the NANDA‐I taxonomy. The review also highlights that it would be necessary to improve the incorporation of a gender approach in the diagnostic formulation and a non‐sexist use of language in the translations of its terminology. Based on the review, the initial document contained 12 open questions that were proposed to the ten gender experts.

Additionally, the experts were informed about the basic terms and characteristics of the NANDA‐I taxonomy. In the first assessment, and based on their expertise in the study of the gender perspective in the diagnoses of different health disciplines (e.g., medicine), the experts proposed some guidelines that should be taken into account; they also had the possibility to formulate new questions. The research team analysed and synthesized the proposals from the gender experts, resulting in 14 preliminary indicators to be considered when analysing or developing NANDA‐I nursing diagnoses from a gender perspective. This process of analysis and synthesis followed the principles of thematic analysis, which was used to assess repeated views and accounts across all data, as outlined by Braun and Clarke (Braun and Clarke 2006). Specifically, the data were analysed to identify recurrent themes, which were then defined and named as the primary indicators of the guideline. Any discrepancies during this process were resolved through team discussion.

The final step before initiating the subsequent Delphi rounds entailed the evaluation of the guidelines by an expert in gender, an expert in the Delphi technique and an expert in nursing diagnoses who belonged to the research team. These reviewers assessed the guidelines and proposed modifications to their organization. The resulting guidelines contained a set of 14 questions distributed across the following three domains: Consideration of differential characteristics by sex and the use of non‐sexist language in the diagnosis; Consideration of the implications of the gender category in the diagnosis; and Consideration of the gender perspective in the translation into other languages.

2.1.2.2. Delphi Formal Rounds: Data Collection and Consensus Definition

The formal proposal was sent to the invited experts including a brief description of the project, its objectives, the expected number of rounds and the estimated length of the process. Furthermore, the invitation included a synthesis of the results from the previous stage, provided as an attached document detailing the mean, standard deviation (SD) for the analysis of response dispersion and proportions obtained for each indicator. It was foreseen that experts would require approximately 30 days to respond in each round, and personalized reminders were sent before the round was finished to those experts who had not responded (Humphrey‐Murto et al. 2017).

The rounds were conceptualized as part of an iterative process. The experts were asked to assess and reach consensus on two main criteria: relevance and feasibility of the items. Both criteria sought to enhance the content and applicability of the guidelines for their use when developing or analysing already existing NANDA‐I nursing diagnoses considering the gender perspective. The process is described as follows:

• –e‐Round 1: First‐round panellists consisting of 10 experts on gender assessed the relevance of the different items of the guidelines following a Likert‐type scale ranging from 1 to 4 (1 “not at all relevant”, 2 “not relevant”, 3 “relevant” and 4 “very relevant”). The experts were asked to justify their decision for each item with qualitative feedback and also to include content that might have not been considered previously.
• –e‐Round 2: The resulting guidelines from e‐Round 1 were analysed by the research team who applied the changes suggested by the first panel of experts. In e‐Round 2, the guidelines were assessed by the panel of 10 nursing diagnoses experts in terms of relevance using a Likert‐type scale ranging from 1 to 4 (1 “not at all relevant”, 2 “not relevant”, 3 “relevant” and 4 “very relevant”) and also in terms of feasibility by means of a Likert‐type scale ranging from 1 to 4 (1 “not at all feasible”, 2 “not feasible”, 3 “feasible” and 4 “very feasible”). In both cases, the experts were asked for the qualitative feedback that justified their assessments, and they were also able to propose content that had not been considered previously. It should be highlighted that the assessment of feasibility in this group of experts also sought to analyse the coherence and compatibility of the guidelines related to the NANDA‐I taxonomy structure.
• –e‐Round 3: The resulting guidelines from e‐Round 2 were reviewed by the research team and sent back to the 10 gender experts and 10 nursing diagnoses experts in order to refine and reach consensus on the final guidelines in terms of content, relevance and feasibility.

The criteria used to decide the level of consensus concerning relevance and feasibility (on the 4‐point Likert scale) were 80% agreement and mean response equal to or greater than 3. This means that at least 80% of the experts selected either ‘3—relevant/feasible’ or ‘4—very relevant/very feasible (Niederberger et al. 2021). These same criteria were maintained to decide the number of rounds with both expert profiles. Items without consensus of relevance were eliminated in the following Delphi round. The items with low consensus or with no consensus in the feasibility domain were reformulated and presented in the following round to guarantee the feasibility of the indicators considered relevant (taking into consideration the ratings of the qualitative feedback of the experts).

2.2. Data Analysis

The designed questionnaire and the questionnaires resulting from the three rounds were amended by the experts and returned to the research team who performed the tasks of synthesis and selection, yielding a manageable set of items, wherein each one is defined as clearly as possible. As this study has been used quantitative rating scales (specifically Likert scales), consensus was evaluated by calculating the percentage agreement, the mean and, for the analysis of response dispersion, the standard deviation of each item according to the scores obtained by the participating experts (Hsu and Sandford 2007 and Franc et al. 2023).

2.3. Ethics Considerations

This research received the approval of the Ethics Committee of Ramon Llull University (CER URL_2022_2023_010) following the principles of the Helsinki Declaration. All participants received information about the research and signed the informed consent form before participating in the study. Only the research team had access to participants' personal information. Data collection through Google forms was anonymous. All participants' identities were kept anonymous by using codes. To ensure confidentiality and data protection, in correspondence between the PI and the participants in the various phases of the DG, personal data (email) were removed from the results matrix. The researchers who analysed the results of the different phases and drafted the final report did not have access to such data.

3. Results

3.1. Demographic Data of Participants

The total number of participants included 20 experts in gender and NANDA‐I nursing diagnoses, of whom 75% were women and 25% were men. The mean age was 49.6 years (SD 9.23). Their fields of study comprised nursing (65%), anthropology (20%), psychology (10%) and pharmacy (5%), with mean experience in the field of 24.7 years (SD 10.05). The level of education included a master's degree (15%) and doctoral degree (85%) studies.

Eighty‐five percent of the participants work in Spain, followed by 5% who work in Mexico and Andorra, respectively. The professional fields of expertise were: research (40%), academic (40%), clinical work (10%) and management (10%) (Table 1: Sociodemographic characteristics of study participants).

TABLE 1.

Sociodemographic characteristics of study participants.

	Gender Experts		NANDA‐I Experts
	n	%	n	%
Participants in each Delphi round (20 participants agreed to participate)	10	50	10	50
Gender	n	%	n	%
Female	8	80%	10	70
Age	Mean	SD	Mean	SD
	47,7	6,13	52,5	10,78
Experience in the field	Mean	SD	Mean	SD
	20,4	7,69	29	10,28
Country of citizenship	n	%	n	%
Spain	10	100	7	70
Portugal	—	—	1	10
Mexico	—	—	1	10
Andorra	—	—	1	10
Level of education	n	%	n	%
Doctoral studies	10	100	7	70
Master	—	—	2	20
Degree	—	—	1	10
Field of studies	n	%	n	%
Nursing	3	30	10	100
Psychology	2	20	—	—
Pharmacy	1	10	—	—
Anthropology	4	40	—	—
Professional field	n	%	n	%
Teaching	4	40	6	60
Research	4	40	1	10
Assistance	1	10	2	20
Management	1	10	1	10

Abbreviation: SD, standard deviation.

3.2. Gender Perspective Indicators: Preliminary e‐Round

The preliminary round was conducted from 15 May until 1 July 2022 (in this particular round, the experts needed a time extension of 15 days to complete the round). Once the 10 experts on gender agreed to participate in our study, an invitation email was sent with the link to access the online platform with the questionnaires. In the body of the invitation email sent to the experts, we explained the process followed by the research team to propose the 14 indicators based on the qualitative responses from the preliminary round.

The first part of the round consisted of sociodemographic data.

The 12 open questions included in the second part that gathered the elements that should be considered for the analysis of NANDA‐I diagnoses from a gender perspective are shown in Table 2: Qualitative questions of the preliminary e‐round.

TABLE 2.

Qualitative questions of preliminary e‐round.

Preliminary e‐Round
Based on the experience of identifying gender when formulating a diagnosis of other disciplines of health sciences, how do you feel sex should be considered as regards the nursing diagnosis? With a regard to diagnostic labelling?
2How should we consider the implications that gender may have in the nursing diagnosis?
3How should we highlight and justify the use of different related factors for both men and women in the formulation of a diagnosis? Why? Under such an assumption, what factors should be included? Could you give an example?
4How should we highlight and justify the use of defining characteristics for both men and women in the formulation of a diagnosis? Why? Under such an assumption, what factors should be included? Could you give an example?
5With regard to related factors and defining characteristics, in what way do you feel that the existence of conflicts with gender identity stemming from social impositions of health‐related and life‐related inequality should be considered, and also with a reference to the diversity of clinical manifestations, avoiding preconceptions and gender stereotypes? Could you give an example?
6What linguistic aspects or nomenclature should be considered so that a nursing diagnosis may be sensitive to gender?
7The edition of the principal source of information of nursing diagnosis correspond to NANDA‐I taxonomy. Such diagnoses are translated from English into different languages for the purpose of research, teaching and care management in different countries, what do you consider to be the risks involved in the use of an international language and its subsequent translation? How should such translation be administered so that the gender perspective can be taken into consideration?
8Is it necessary, in order to formulate a nursing diagnosis, to visualize health‐related, care‐related, illness‐related situations that are specifically territorial (whether recognized or not) involving women, such as care tasks? Why? Could you give an example?
9What aspects of different and unequal health‐related situations involving women should be specified in such diagnoses? Why?
10What do you consider to be the aspects of different and unequal situations involving people, which determine the management of health‐related procedures of health/illness/care, that should be specified in such diagnoses? Why?
11Do you feel it is necessary that the nursing diagnosis could include the option of including additional information that relates how cases of gender‐related intersection (identity, inequalities and power‐related dynamics) influence contextual and structural factors and may determine people's health?
12Nursing is the science of integral care, and, as such, provides care for individuals, families and communities, both personal and in close contact. Do you consider that there is the opportunity to include gender analysis specifically in this discipline, in order to progress towards equality with regard to the approaches that dominate in the fields of health/illness/care? Could you give an example?

After completing this preliminary round, the research team met to discuss the results and agreed on the content of e‐Round 1. The guidelines resulting from this round were organized according to 3 domains with a total of 14 items. The domains or dimensions included in our framework which served as the umbrella for the different indicators were as follows: Consideration of differentiating characteristics in terms of sex, if applicable, and the use of non‐sexist language in the diagnosis; Consideration of the implications of gender in the diagnosis; and Consideration of the perspective of gender when translated into other languages.

The changes across the three waves can be seen in Table 3 and are described in the next section.

TABLE 3.

Overview of results from the Delphi rounds and overall consensus for each round.

	e‐Round 1 (Gender experts)			e‐Round 2 (NANDA‐I experts)					e‐Round 3 (Gender & NANDA‐I experts)
	Mean (SD)	Consensus achieved (relevant or very relevant) %	Action	Mean (SD)	Consensus achieved (relevant or very relevant) %	Mean (SD)	Consensus achieved (feasible or very feasible) %	Action	Mean (SD)	Consensus achieved (relevant or very relevant) %	Mean (SD)	Consensus Achieved (feasible or very feasible) %
Consideration of differentiating characteristics in terms of sex, if applicable, and the use of non‐sexist language in the diagnosis
In all elements of the diagnosis the use of non‐sexist language has been taken into consideration Round 2 Clarification: in the introduction of round 3 it is added that the tool aims to convert what is relevant into achievable	3,5 (0,5)	100	—	3,5 (0,80)	80	2,7 (0,74)	70	C	3,35 (0,85)	85	3,3 (0,84)	85
2Enunciation of sex in terms of men and women was used to reflect biological differences and gender differences and gender diversity is taken into account before socio‐cultural aspects	3,5 (0,92)	90	—	3,6 (0,46)	100	3,1 (0,51)	90	—	3,55 (0,80)	80	3,1 (0,94)	80
3The use of binary terminology has been avoided and has been substituted by the term person providing that this does not conceal processes applied to a particular sex	3,5 (0,80)	80	—	3,5 (0,63)	90	3,1 (1,08)	90	—	3,65 (0,57)	95	3,8 (0,80)	95
Consideration of the implications of gender in the diagnosis
The need to detect different ways of falling ill, of caring, of expressing symptoms and discomfort is met, in order to seek specific formats of care, prevention and health promotion Round 2 Clarification: in the introduction of round 3 it is added that the tool aims to convert what is relevant into achievable	3,8 (0,4)	100	—	3,3 (0,64)	90	2,6 (0,76)	60	C	3,75 (0,53)	95	3,25 (0,76)	80
2Differentiation of the implications of gender in the different elements of diagnosis is supported with scientific evidence	3,8 (0,4)	100	—	3,7 (0,64)	90	3,1 (0,51)	90	—	3,65 (0,65)	90	3,05 (0,73)	80
3The diagnosis label states the sex when the anatomic‐physiological differences between men and women have a bearing on their responses	3,1 (1,13)	80	—	3,5 (0,80)	80	3,6 (0,46)	100	—	3,4 (0,8)	80	3,4 (0,8)	80
4Gender stereotypes that lead to a particular type of behaviour are regarded as a Risk Factor	3,7 (0,45)	100	—	3,8 (0,4)	100	3,6 (0,46)	100	—	3,7 (0,64)	90	3,3 (0,71)	85
5 When formulating related factors that are different for men and women the influence of determining health‐related factors (gender, age, socioeconomic level, care‐related responsibility, work situation, rural/urban location, level of education) are all taken into consideration in accordance with their level of exposure to inequality when these can be modified by the nurse Round 1 clarification: (*) the taxonomy considers Risk Factors casual factors that can be modified by the nurse and a Risk Population coincidental factor that cannot be modified by the nurse	3,6 (0,48)	100	C	3,8 (0,6)	100	3,4 (0,76)	80	—	3,45 (0,86)	85	3,05 (0,92)	80
6 Health‐related determining factors (age, socioeconomic level, care‐related responsibility, work situation, rural/urban location, level of education) that cannot be modified by the nurse have been considered in the diagnosis as a Risk Population Round 1 clarification: (*) the taxonomy considers Risk Factors casual factors that can be modified by the nurse and a Risk Population coincidental factor that cannot be modified by the nurse	3 (1)	70	C	3,8 (0,6)	100	3,2 (0,93)	80	—	3,35 (0,85)	85	3,05 (1,02)	80
7 Defining characteristics include specific signs and symptoms of the biology of men and women and expression of gender‐related roles taken on, in such a way that the nursing diagnosis is precise based on scientific evidence Round 2 reformulation: Defining characteristics include specific signs of the biology of men and women and symptoms or expression of gender‐related roles taken on, in such a way that the nursing diagnosis is precise based on scientific evidence	3,5 (0,67)	90	—	3,6 (0,8)	100	2,8 (0,83)	50	R	3,65 (0,57)	95	3,05 (0,80)	80
8 Gender‐related conditioning factors are taken into consideration as modulators of health‐related responses and may even cause a conflict with a person's wishes/needs Round 1 clarification: gender‐related conditioning factors (*) assigned roles, attitudes and demands in response to gender ideals in accordance with cultural models Round 2 reformulation: Throughout the entire process involved (new diagnosis proposal, research…), conflicts between the person's wishes and needs that may have generated gender‐related conditioning factors have been taken into consideration (*) (*) (assigned roles, attitudes and demands in response to gender ideals in accordance with cultural models)	3,3 (0,64)	90	C	3 (1,18)	70	2,6 (1,06)	50	R	3,1 (0,7)	80	3,01 (0,83)	80
Consideration of the perspective of gender when translated into other languages
The process of translation has been carried out following the usual process of linguistic ‐ cultural adaptation of a process to validate a questionnaire.	3 (0,89)	80	—	4 (0)	100	3,8 (0,38)	100	—	3,7 (0,55)	95	3,6 (0,66)	90
2If there has been a translation into other languages, this contemplates the gender perspective, with the corresponding references and/or guides of good practice.	3,16 (0,48)	100	—	3,5 (0,67)	90	3,3 (0,74)	80	—	3,65 (0,65)	90	3,6 (0,48)	100
3 The review also involves expert translators concerning the gender perspective, and are cited along with the rest of the translation team Round 2 reformulation: A post‐translation review is carried out by experts in gender, who collaborate with the rest of the translation team	3,2 (0,6)	90	—	3,5 (0,67)	70	2,8 (0,83)	50	R	3,45 (0,66)	90	3,55 (0,66)	90

Abbreviations: C, clarification; R, reformulation.

3.3. E‐Round 1

The first round was conducted from 1 to 30 October 2022. Once the 10 experts on gender agreed to participate in our study, an invitation email was sent with the link to access the online platform with the guidelines. The first part of the round consisted of the collection of sociodemographic data. The guidelines included 14 items distributed across three domains.

All the items achieved a mean of > 3 and 80% agreement on their relevance. Some qualitative feedback was gathered from the experts.

After the first round was completed, the research team met to discuss the results and agree on the content of e‐Round 2. As all the items achieved a mean of ≥ 3 and 80% agreement, in e‐Round 2 the same questionnaire was sent to the experts in nursing diagnoses, including a clarification regarding the structure of the NANDA‐I taxonomy, in items 5, 6 and 8 from domain 2, based on the qualitative feedback of the experts in e‐Round 1. In their qualitative feedback, the gender experts noted that, although they considered them relevant, they gave lower scores to certain indicators that they found unclear, as these were closely linked to the NANDA‐I structure; consequently, they requested a reformulation for the next round in which they were to participate.

3.4. E‐Round 2

The second round was conducted between 15 December 2022 and 25 January 2023. Once the 10 experts on nursing diagnoses agreed to participate in our study, an invitation email was sent with the link to access the online platform with the questionnaire. The first part of the questionnaire consisted of sociodemographic data. Similar to the previous round with the gender experts, in terms of relevance, all items achieved a mean of ≥ 3 and 80% agreement. In terms of feasibility, based on the consensus achieved (50%–60%) the experts agreed that five of the 14 items needed to be reformulated or required further clarification. Specifically, it was necessary to include a clear clarification in the introduction of the questionnaire about the purpose of the guideline. Additionally, items 7 and 8 in Domain 2 and item 3 in Domain 3 needed to be reformulated for e‐Round 3. In their qualitative feedback, the experts of nursing diagnoses noted that they gave lower feasibility scores to these items because they were unclear (particularly for the gender experts); however, they considered them relevant and proposed specific clarifications or reformulations to be addressed in subsequent rounds.

3.5. E‐Round 3

The third round was conducted between 25 February and 15 March 2023 and involved the participation of 20 experts (this final round included both expert profiles). In terms of relevance and feasibility, all items achieved a mean of ≥ 3 and 80% agreement.

A synthesis of the process of the Delphi study and the main results of each round can be seen in Figure 1: Description of the Delphi phases.

FIGURE 1.

Description of the Delphi phases.

The final guidelines include 14 items within three domains shown in Table 4.

TABLE 4.

Engender NANDA: Final guidelines.

	Yes	No
Consideration of differentiating characteristics in terms of sex, if applicable, and the use of non‐sexist language in the diagnosis
In all elements of the diagnosis the use of non‐sexist language has been taken into consideration
2Enunciation of sex in terms of men and women was used to reflect biological differences and gender differences and gender diversity is taken into account before socio‐cultural aspects
3The use of binary terminology has been avoided and has been substituted by the term person providing that this does not conceal processes applied to a particular sex
Consideration of the implications and conditioning factors of gender in the diagnosis
The need to detect different ways of falling ill, of caring, of expressing symptoms and discomfort is met, in order to seek specific formats of care, prevention and health promotion has been considered
2Differentiation of the implications of gender in the different elements of diagnosis is supported with scientific evidence
3The diagnosis label states the sex when the anatomic‐physiological differences between men and women have a bearing on their responses
4Gender stereotypes that lead to a particular type of behaviour are regarded as a Risk Factor
5 When formulating Related factors that are different for men and women the influence of determining health‐related factors (gender, age, socioeconomic level, care‐related responsibility, work situation, rural/urban location, level of education) are all taken into consideration in accordance with their level of exposure to inequality when these can be modified by the nurse (*) the taxonomy considers Related Factors causal factors that can be modified by the nurse and a Risk Population coincidental factor that cannot be modified by the nurse
6 Health‐related determining factors (age, socioeconomic level, care‐related responsibility, work situation, rural/urban location, level of education) that cannot be modified by the nurse have been considered in the diagnosis as a Risk Population (*) the taxonomy considers Risk Factors causal factors that can be modified by the nurse and a Risk Population coincidental factor that cannot be modified by the nurse
7Defining characteristics include specific signs of the biology of men and women and symptoms or expression of gender‐related roles taken on, in such a way that the nursing diagnosis is precise based on scientific evidence
8 Throughout the process carried out (new diagnostic proposal, research…), conflicts between the wishes and needs of the person that may have generated by learned gender‐related conditioning factors (*) are taken into account. (*) (assigned roles, attitudes and demands to respond to gender‐related ideals in accordance with cultural models)
Consideration of the perspective of gender when translated into other languages
The process of translation has been carried out following the usual process of linguistic ‐ cultural adaptation of a process to validate a questionnaire.
2If there has been a translation into other languages, this contemplates the gender perspective, with the corresponding references and/or guides of good practice.
3A post‐translation review is carried out by experts in gender, who collaborate with the rest of the translation team

4. Discussion

To the best of my knowledge, this is the first study to develop a guideline for the integration of the gender perspective in the use of NANDA‐I nursing diagnoses that can be applied in the fields of teaching, research and clinical practice. A Delphi study was conducted in order to reach agreement on the different elements for including in the guideline, with a final consensus consisting of a set of 14 indicators within three domains that include the consideration of differential characteristics by sex and the use of non‐sexist language in the diagnosis, as well as the implications of the gender category in the diagnosis, and finally the consideration of the gender perspective in translation into other languages.

The present study has been conducted following a rigorous process which involved the participation of an international panel of experts with various backgrounds and great expertise on the gender perspective and nursing languages; the definition of 12 open questions formulated on the basis of the systematic review (Rifà‐Ros et al. 2023) conducted by the research team that gathered the elements that should be considered for the analysis of the NANDA‐I diagnoses from a gender perspective, and the adherence to international guidelines for conducting a Delphi study (Jünger et al. 2017).

Overall, it is observed that there is consensus on the need for the use of non‐sexist language in diagnosis. Given the linguistic variations, the use of the generic masculine cannot be explained (Baxter 2005), due to the existence of scientific evidence of the differences between the sexes, which also implies the need to adapt to non‐normative patterns in terms of gender and the way of calling oneself that, as in other disciplines (Ansara and Hegarty 2013), must be reflected in nursing diagnoses. All these aspects are reflected in the three indicators within the dimension Consideration of differentiating characteristics in terms of sex, if applicable, and the use of non‐sexist language in the diagnosis, as presented in Table 4.

Even today in the health sciences, the invisibility of differential morbidity between women and men to avoid gender bias is denounced (Rodríguez‐Soza and Ruiz‐Cantero 2022), hence among our experts a high degree of consensus was generated concerning the need for diagnosis by sex, to highlight biological differences, in addition to the need to consider gender diversity in the face of the socio‐cultural aspects that determine individuals' health responses. These aspects, highlighted by the consulted experts, are reflected in the first three indicators of the dimension Consideration of the implications and conditioning factors of gender in the diagnosis of the ENGENDER NANDA guideline (Table 4).

The use of binary terminology has caused fractures in recent decades, which need to be overcome for the advancement of health disciplines and towards equity (Connell 2012). The very process of this research has demonstrated this possibility, since in the last rounds, greater consensus has been noted when reflecting on the need to replace the binary vision with the term person, provided that it does not mean rendering processes that occur in a given sex invisible. With this update, greater adaptability to people and their contexts can be achieved. Both the intersectional approach, against the competition of non‐situated experiences of vulnerability (Coll‐Planas et al. 2023), and the post‐structuralist vision, in the sense of being able to break with the norm and social control, or status quo, as a process of improvement, give us the opportunity to observe how important it is for nurses to know how, first and be able, second, to adapt to the characteristics of the people cared for. For this reason, maintaining this item (The use of binary terminology has been avoided and has been substituted by the term person providing that this does not conceal processes applied to a particular sex) was considered feasible and appropriate.

Beyond recognizing biological differences where these are supported by evidence, the expert panel also reached strong consensus on the need to systematically integrate the broader implications of gender into clinical reasoning. Gender roles, norms and structural inequalities shape people's experiences, opportunities and health responses, and therefore should be considered when formulating nursing diagnoses. This perspective is reflected throughout the second domain of the ENGENDER guideline and is consistent with previous literature highlighting the importance of gender‐sensitive clinical reasoning (Shannon et al. 2019).

Nurses are tasked with providing evidence of the existing gender biases in the diagnostic process, but also in the nursing interventions themselves that constitute the monitoring of people's health situations (McDonald and Gary Bridge 1991). Proposals for improving self‐care involve focusing on people's characteristics and experiences, from an intersectional perspective, considering the structural factors that determine oppression and violence, power relations and loss of opportunities, to achieve progress in nursing research (Coll‐Planas and San Martín 2023).

In addition, the need has been seen to demonstrate how the factors that bring us closer to the cause of the diagnosis (related factors) can be closely linked to gender stereotypes and the interaction of gender demands with socio‐economic aspects (Sen and Östlin 2008) which, if they can be modified by the nurse, should serve as a priority to steer healthier behaviours in the people and populations we care for. In these situations, moreover, several authors have highlighted the need, in order to achieve more equitable states of health, to focus on the environment, which causes different ways of falling ill. Although this intersectional perspective can be considered transversal throughout the guideline, it is primarily reflected in indicators 5 and 6 of the dimension Consideration of the implications and conditioning factors of gender in the diagnosis (Table 4).

The evidence suggested by decision‐making in diagnosis (defining characteristics) must be based on the application of the gender approach in nursing, on the identification and registration of differences between women and men, as is increasingly performed in certain disciplines and specific processes (Peters et al. 2014). Along the same lines, studies already exist on this difference for certain diseases, when we contextualize the health situation of non‐normative sex‐gender people (Alzahrani et al. 2019). Incorporating assumed gender roles or expressions that can determine people's discomforts also improves diagnostic accuracy. Incorporating assumed gender roles or expressions that can determine people's discomforts also improves diagnostic accuracy, as reflected in the guideline's indicator: Defining characteristics include specific signs of the biology of men and women and symptoms or expression of gender‐related roles taken on, in such a way that the nursing diagnosis is precise based on scientific evidence.

However, in their qualitative arguments, the participants have stressed the need for scientific evidence in this regard, larger and more precise studies on how the sex‐gender system affects the consideration of differences between women and men in terms of their care needs and follow‐up, as well as the impact of static considerations on gender identities on health and healthcare and the necessary evaluation of gender‐sensitive nursing interventions. In response to this challenge, the guideline explicitly incorporates the indicator: Differentiation of the implications of gender in the different elements of diagnosis is supported with scientific evidence. This addition addresses the identified gaps and establishes a new approach for future lines of research in nursing.

Despite its important contribution as the first guideline for integrating a gender perspective into NANDA‐I nursing diagnoses, this study has several limitations, primarily stemming from the inherent nature of the Delphi technique, which relies on subjective expert opinion rather than empirical data, potentially introducing biases and limiting generalizability due to the relatively small and geographically concentrated expert panel (85% from Spain). Furthermore, while the study's focus on NANDA‐I is valuable, its direct applicability to other nursing classification systems is not established, and the interpretation of initial qualitative data involved inherent subjectivity, while the lack of explicit consensus criteria for this preliminary round could introduce a less transparent step in the guideline's development. To address these limitations, future research must focus on subsequent validation studies to evaluate the guideline's applicability, acceptability and impact in real clinical environments, which will help establish its effectiveness and feasibility across different healthcare settings. Additionally, given the predominance of Spanish experts in the panel, further studies are required to explore how cultural, linguistic and healthcare‐system differences may influence the transferability of the ENGENDER guideline to other countries and international regions.

Finally, the proposed guideline offers strategies for the consideration of the gender perspective in translation into other languages. It is recommended that the translation process should be accurate, in the style of gender‐sensitive validation studies which implies adaptation to the practical guidelines and accepted actions on research (Van Epps et al. 2022; Welch et al. 2017) by the scientific community in each context. In addition, the recommendation cited by the experts regarding the need for translations to be reviewed by a committee of gender experts, as well as for the latter to be acknowledged together with the rest of the team, represents a further step in making the role of women visible and eliminating gender inequality in the recognition and leadership of nurses. These recommendations are explicitly captured in the three indicators that comprise the dimension Consideration of the perspective of gender when translated into other languages within the guideline.

The final guideline can help nurses in considering the gender perspective when they use language that makes their professional contribution visible within the team, which also ensures more ethics and equitable professional performance that is more adapted to specific needs.

To ensure the practical implementation and operationalization of the ENGENDER guideline across clinical, educational and research settings, several strategic actions should be pursued. In the clinical area, operationalizing these guidelines requires the identification and integration of gender‐differentiated defining characteristics and related factors directly into electronic health records. This integration serves as a guarantee for individualized care that systematically embeds a gender perspective, thereby enhancing the precision and efficiency of nursing interventions by focusing directly on specific patient responses. In educational environments, incorporating these evidence‐based recommendations brings greater scientific rigour to training. Nursing diagnoses must shift from being mere complements to becoming the central, transversal axis across all subjects, moving away from the traditional, pathology‐centered focus that currently structures most curricula. Finally, in the field of nursing research, the guideline establishes clear criteria for reviewing the current NANDA‐I taxonomy and proposing new diagnoses, providing a framework that should be incorporated into the existing guidelines provided by NANDA‐I itself, fostering a more robust, evidence‐based integration of the sex‐gender system in future nursing knowledge development.

5. Conclusions

This article developed ENGENDER NANDA Guideline, a pioneering framework for integrating a comprehensive gender perspective into the use of NANDA‐I nursing diagnoses.

Throughout the manuscript, the process of reflection and creation of the 14 indicators organized into three domains is developed. The guideline integrates the consideration of differentiating characteristics in terms of sex, the use of non‐sexist language in the diagnosis, the impact of the consideration of the gender perspective in the process of clinical reasoning, and the need for including gender experts in the process of translating NANDA‐I language into languages that use binary gender nouns.

The resulting guideline represents a significant step forward for nursing, moving beyond traditional binary approaches to gender and advocating for an intersectional lens that acknowledges the complex interplay of gender with other social determinants of health.

6. Relevance to Nursing Practice

In terms of the expected impact of our research in the clinical field, it is the first guideline for the consideration of the gender perspective for teaching, research and clinical practice in the in the use of NANDA‐I nursing diagnoses. The scientific literature shows that gender inequalities exist and can be found in different health scenarios. In addition, health and gender determinants in the last decades have pointed out the need to understand the different subjectivities and needs of every human being. Consequently, conducting research on this topic is relevant. Systematically Incorporating the gender approach in nursing diagnoses shall lead to the design of more precise, efficient and inclusive care plans. This is imperative in terms of ethics and quality of care.

This project seeks to identify the specific aspects that must be considered in order to analyse each nursing diagnosis integrating gender relations and roles with a perspective beyond binarism and improve the visibility of the possible existence of a gender bias in the NANDA‐I diagnostics taxonomy and to raise nurses' awareness of the need to include the gender perspective in their day‐to‐day work.

Consideration of the gender perspective of nursing diagnoses contained in the NANDA‐I taxonomy and their use in teaching, research and clinical practice will enable correcting any existing biases and subsequently adapting nursing language to describe the specific responses of different life and health situations. Only then will care plans be designed tailored to the diversity of social and health needs; at that time, adequate resources could be allocated and research conducted to advance in the knowledge of ethics and inclusive care.

In addition, the results of this research will allow opening a research field of gender perspective in each of the diagnoses contained in the taxonomy.

Author Contributions

Miriam Rodriguez‐Monforte: investigation, writing – original draft, writing – review and editing. Mª Rosa Rifà‐Ros: conceptualization, methodology, writing – original draft, investigation, supervision. Angel Gasch‐Gallen: conceptualization, investigation, writing – review and editing. Elena Carrillo‐Alvarez: investigation, supervision, writing – review and editing.

Funding

This research was supported by This research has received funding from The NANDA FOUNDATION, Marjory Gordon Program, 2023.

Ethics Statement

The ethics committee of the Ramon Llull University approved the study prior to data collection (CER URL_2022_2023_010).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethics restrictions.