To identify, describe and analyse the gender perspective in the use of the diagnoses contained in the NANDA-I taxonomy in observational studies published in the scientific literature.

Design and methods

A systematic review has been conducted spanning from 2002 to 2020. The most frequent NANDA-I nursing diagnoses in care plans reported in observational studies, and the defining characteristics and related factors identified for men and women have been described. The Preferred Reporting Items for Systematic Reviews (PRISMA-P) have guided our research.

The main findings have been summarized using a descriptive narrative synthesis approach.

Results

Forty-one articles were included in our study. With regard to gender analysis, the percentage of men and women that make up the sample were not specified in all articles, and half of the studies did not identify gender either in the diagnosis label or in their defining characteristics or related factors.

Based on the reviewed articles, gender perspectives are not systematically incorporated in the use of the NANDA-I diagnosis. Therefore, gender biases in its use in the scientific literature may exist. This situation poses barriers to determine the health responses that are different and unequal between women and men.

1 INTRODUCTION

Health is a complex process determined by the interrelation of biological, environmental, psychological and social factors and it can be experienced differently by women and men (Valls-Llobet, 2003, 2011). In this sense, gender, social class and culture, among others, are determinants in the health-disease process, which is why differences and inequalities in health due to sex/gender can also occur (Rifà-Ros et al., 2018; Ruiz-Cantero & Verdú-Delgado, 2004).

According to the World Health Organization (WHO), gender refers to the roles, behaviours, activities and attributes that a given society considers appropriate for men, women, boys, girls and people with non-binary identities (World Health Organization, 2018). In contemporary globalized societies and in regards to health, gender is understood as a socio-cultural construct that becomes normative when imposed on each of the sexes through the process of socialization and by establishing behavioural models. These processes imply several expectancies that have a statistically significant impact on people's health and also on healthcare delivery (Gupta et al., 2019).

At present, and in order to meet the individuals' health needs and avoid an essentialist vision, gender categories should be broadly considered, integrating gender relations and roles and a perspective beyond binarism. However, studies show that social and health systems have very rarely considered the gender perspective, yielding ineffective health outcomes and also the suffering of bodily effects (Connell, 2012).

In the past decade, a large amount of evidence about sex differences in health phenomena (Lin et al., 2019; Wenham et al., 2020; Zeng et al., 2020), differential morbidity (Valls-Llobet et al., 2008) and biases in diagnostic and therapeutic efforts have emerged (Moreno Campoy et al., 2015; Westergaard et al., 2019). These biases can lead, among others, to non-effective and non-equitable responses by health professionals, including nurses, to the needs of individuals and communities (Cascella Carbó & García-Orellán, 2020; Crespí-Lloréns et al., 2021). It has been argued that these biases of clinical interpretation and treatment can be avoided with the construction of further evidence on the existing differences of the clinical manifestations of illness for women and men (Ruiz-Cantero & Verdú-Delgado, 2004).

The need to develop sensitive research on this topic has been highlighted in several studies and recommendations, both for researchers and for specific clinical interventions for its impact in health care, research, management and education (Figueroa Perea, 2003; Ruiz-Cantero et al., 2019; Velasco-Arias, 2009). Likewise, Wright (2014) concluded that gender determinants must be integrated into clinical practice in order to provide comprehensive care, and that research and analysis from a psychosocial perspective must be promoted for the determination of these factors.

According to Rohlfs, in order to design health assessments that allow for an analysis from the gender perspective, sociodemographic and occupational variables, morbidity, perceived health, quality of life, mental health, chronic conditions and social support must be taken into consideration (Rohlfs et al., 2007).

Considering this biopsychosocial perspective, the NANDA-I taxonomy is a widely used nomenclature and ordering system for nursing diagnoses that allows for the description of people's human responses to different health and life situations (Herdman et al., 2021). Some of the areas included in the domains of the NANDA-I have been studied from a gender perspective. For example, various studies have concluded that the greater perception of health deterioration as a consequence of the care provided manifested by women compared to men caregivers is related to the fact that women are subject to a greater perception of responsibility for care, and also to the fact that the characteristics of the care provided are more intense and require greater dedication (Ferré-Grau et al., 2014; García Calvente et al., 2011; Sutherland et al., 2017; Vafaei et al., 2016). Additional, evidence in the same line concludes that the adoption of different lifestyles by women and men is influenced by socially established norms and roles, which lead to health inequalities (Wright, 2014). Moreover, focusing on nursing diagnoses (with its defining characteristics [DC] and related factors [RF]) to get information from the experiences and individual narratives, allows an in-depth approach to understanding the impact of the imposition of gender in the individual health responses (García Calvente & Marcos Marcos, 2011).

The present study aims to identify and analyse the gender perspective in the use of the nursing diagnoses contained in the NANDA-I taxonomy. Nursing diagnoses are essential in defining the nursing profession and its point of view since they allow for descriptions of nursing care, the comparison of data for research, and the development of health policies appropriate to the social demands of the moment (Rifà-Ros & Pérez-Pérez, 2009). Today, these demands include considering the gender perspective in the responses and behaviours that people display in health and/or life situations.

2 OBJECTIVES

The general objective of our study is to identify, describe and analyse the gender perspective in the use of the diagnoses contained in the NANDA-I taxonomy in observational studies published in the scientific literature. The specific objectives of the study are: to describe the general characteristics of the studies that use NANDA-I diagnoses applied to care plans for men and women; to identify the most frequent nursing diagnoses applied to care plans designed for men and women; and to list the defining characteristics (DC) and related factors (RF) identified for men and women.

3 METHODS

A systematic review of the literature has been conducted, spanning from 2002 (year of reorganization of Taxonomy II) to June 2020. The most frequent NANDA-I nursing diagnoses in care plans reported in observational studies, and the DC and RF identified for men and women, have been described. The Preferred Reporting Items for Systematic Reviews (Page et al., 2021) have guided our research. The selection of this type of methodology allows identify gaps, deficiencies and trends in the current evidence of gender perspective in the use in the scientific literature of the diagnoses contained in the NANDA-I taxonomy and can help underpin and inform future research in this area (Munn et al., 2018).

3.1 Search

The research question that guided our search strategy was: Is the gender perspective considered in the use of NANDA-I diagnoses in observational studies published in the scientific literature?

The search was carried out in the main bibliographic health sciences databases: Dialnet, Pubmed, Cuiden, Lilacs, Scopus, Cinahl Complete TDX, Teseo and Cochrane.

The terms and descriptors DeCS and MeSH have been used and organized into three main topics: care plans, nursing diagnoses and use. The main descriptors developed were “NANDA-I diagnoses,” “male,” “female,” “gender,” “standardized Nursing Terminology,” “diagnoses” and “gender”. Then, the different descriptors were adapted to generate an equation for each database considering the adaptation to its different languages (e.g. Spanish and Catalan). The search strategy defined is shown in Table 1.

TABLE 1. Search terms per databases

Database	Search Terms
Cuiden Dialnet Lilacs	Diagnósticos NANDA AND mujer diagnósticos NANDA AND hombre diagnósticos NANDA AND género
TDX	Diagnòstic d'infermeria
Cochrane Teseo	Diagnóstico enfermería
Pubmed Scopus	“Standardized Nursing Terminology”[Mesh] OR “Diagnosis”[Mesh] AND Gender[MESH] NOT “Transgender”
Cinahl Complete	SU standardized nursing terminology OR SU diagnosis AND SU gender NOT SU transgender

3.2 Eligibility criteria

The selection criteria for the inclusion of the different studies were: (a) observational studies that describe the application of care plans to male and female using NANDA-I taxonomy; studies published from January 2002 (year of reorganization of Taxonomy II) to June 2020. No language restrictions were applied. In terms of the interpretation of the studies, our research team had different researchers who could fluently speak English, Spanish and Portuguese as they are considered first languages for them. Moreover, if any of the papers had to be translated or there were interpretation issues, authors would have been contacted.

3.3 Data collection process

The articles obtained through the search strategy underwent an initial peer-review screening based on the title and abstract. Next, a full-text review was performed by the same two investigators. Any discrepancies were resolved by consensus. The authors of the original studies were contacted if relevant information on eligibility or key study data was not available in the published report. The primary search was carried out from July to December 2020 and 3,496 articles were retrieved (after eliminating duplicates) of which 67 were accepted. The main reasons for discarding the remaining documents were because they consisted of a description of a clinical case; they outlined theoretical care plans; no abstract was available; or because the NANDA-I taxonomy was not used.

3.4 Data abstraction

Data were abstracted by two independent reviewers (MR-RR) and compared, using a specific form in which the authors described the information of interest. The study variables included: year of publication; country where the study was conducted; study method; clinical field of the study; NANDA-I taxonomy edition; diagnosis label (DL); defining characteristics (DC) and related factors (RF); and gender (male/female/other/not identified).

3.5 Quality assessment

In order to assess the quality of the studies included, we used the mixed methods appraisal tool (MMAT). This tool has been validated and allows the appraisal of most common types of study methodologies and designs. In the case of our review only the section of quantitative descriptive studies was used (Pace et al., 2012).

3.6 Data analysis

The main findings were summarized using a descriptive narrative synthesis approach that enables investigation of similarities and differences between studies, exploration of relationships in the data and assessment of the strength of the evidence and results in a summary of knowledge related to a specific review question that may be used to inform practice or policy (Lisy & Porritt, 2016).

4 RESULTS

Initially, 3,496 records were identified and peer-reviewed based on the title and abstract. Subsequently, 67 articles were selected for full-text reading. Finally, 38 articles were included in our study. The flow diagram of this process is shown in Figure 1.

Details are in the caption following the image — **FIGURE 1**
Open in figure viewer PowerPoint

Flow diagram of study selection process

4.1 General characteristics of the studies included

The objectives of the 38 studies analysed can be grouped into three types: 23 seeked to identify the nursing diagnoses present in specific patient groups/populations; 10 aimed to identify diagnoses belonging to specific domains or classes of the NANDA-I Taxonomy II; and four intended to identify the presence of a specific nursing diagnosis in a specific population. Finally, a single study (de Carvalho-Medeiros et al., 2010) aimed to verify the association between DC and the variables: gender, age, weight and height of children in kindergarten. The summary of the characteristics of the studies included in our review is shown in Table 2.

TABLE 2. General characteristics of included studies

Author (publication year), Nanda edition	Country	Objective	Methods	Clinical field/population	Sample gender	Nursing diagnoses gender identification	DC and RF gender identification
Albert-Sobrino et al. (2005), 2003	Spain	To determine how a group of adolescents perceive their body image from a nursing perspective	Cross-sectional study	School- teenagers	M 46.7% F 53.3%	00053 Social isolation (female); 00120 Situational low self-esteem (female)	Unidentified
Lara Lara et al. (2010), 2007	Spain	To determine the nursing diagnosis of the hospital discharge that needs continuity of care. To identify the nurses interventions in an outpatient cardiology clinic	Cross-sectional study	Hospitalization units - hospital discharge in cardiology unit	M 49.2% F 50.8%	Unidentified	Unidentified
De Carvalho-Medeiros et al. (2010), 2009	Brazil	To determine the occurrence of the DC of nutritional nursing diagnoses, verifying the association between the DC and the variables: gender, age, weight and height	Cross-sectional study	School- children	M 42.1% F 57.9%	00163 Readiness for enhanced nutrition (female); 00002 Imbalanced nutrition: less than body requirements (male)	(00163 DC) Expresses desire to enhance nutrition (female); (00002 DC) Pale mucous membranes (male)
de Oliveira Alexandre et al. (2017), NA	Brazil	To evaluate the quality of life and the nursing diagnoses of women with AIDS	Cross-sectional study	Outpatient units - women	F 100%	00214 Impaired comfort; 00096 Sleep deprivation; 00093 Fatigue; 00131 Impaired memory; 00120 Situational low self-esteem; 00146 Anxiety; 00241 Impaired mood regulation; 00088 Impaired walking; 00092 Activity intolerance; 00052 Impaired social interaction; 00065 Ineffective sexuality pattern; 00097 Decreased diversional activity engagement; 00148 Fear; 00147 Death Anxiety	(00214 RF) Treatment regimen; (00214 FR) Illness-related symptoms; (00214 DC) Discontent with situation; (00214 DC) Distressing symptoms; (00096 RF) Prolonged discomfort; (00096 RF) Treatment regimen; (00096 DC) Fatigue; (00096 DC) Drowsiness; (00093 RF) Physical deconditioning; (00093 DC) Impaired ability to maintain usual routines; (00093 DC) Insufficient energy; 00131 RF/DC unidentified (00120 RF) Alteration in body image; (00120 DC) Self-negating verbalizations; (00146 RF) Sressors; (00146 DC) Anguish; (00146 DC) Apprehensiveness; (00146 DC) Fear; (00241 RF) Anxiety; (00241 RF) Impaired social functioning; (000241 DC) Hopelessness; (00088 RF) Pain; (00088 DC) Impaired ability to walk required distance; (00092 RF) Generalized weakness; (00092 DC) Exertional discomfort; (00092 DC) Fatigue; (00052 RF) Absence of statistically significant other; (00052 DC) Dissatisfaction with social engagement; (00065 RF) Insufficient knowledge about alternatives related to sexuality; (00065 DC) Alteration in sexual behaviour; (00097 RF) Inadequate available activities; (00097 DC) Boredom; 00148 RF/DC unidentified (00147 RF) Perceived imminence of death; (00147 RF) Uncertainty of prognosis; (00147 DC) Negative thoughts related to death and dying; (00147 DC) Fear of premature death
Vieira, Bachion, Marques Salge, et al. (2010), 2007	Brazil	To analyse the occurring of 22 diagnosis of nursing interests into the puerperium immediate and late	Cross-sectional study	Primary care- women in puerperium	F 100%	00126 Deficient knowledge; 00104 Ineffective breastfeeding; 00046 Impaired skin integrity; 00146 Anxiety; 00002 Imbalanced nutrition: less than body requirements; 00015 Risk for Constipation; 00132 Acute pain; 00095 Insomnia; 00208 Readiness for enhanced childbearing process; 00227 Risk for ineffective childbearing process; 00221 Ineffective childbearing process; 00120 Situational low self-esteem; 00153 Risk for situational low self-esteem; 00148 Fear	unidentified
Xavier De Lemos et al. (2012), 2009	Brazil	To identify key problems and complications of the puerperium and elaborate nursing diagnoses, according to the NANDA Taxonomy II relevant to each problem	Cross-sectional study	Hospitalization units- women in puerperium	F 100%	00227 Risk for ineffective childbearing process; 00004 Risk for infection; 00197 Risk for Dysfunctional gastrointestinal motility; 00046 Impaired skin integrity; 00153 Risk for situational low self-esteem; 00026 Excess fluid volume; 00066 Spiritual distress; 00062 Risk for caregiver role strain; 00088 Impaired walking; 00104 Ineffective breastfeeding	not matching with NANDA
Assunção Queiroz et al. (2013), 2009	Brazil	To examine the accuracy of indicators for the nursing diagnosis of sexual dysfunction in pregnant women	Cross-sectional study	Primary care-pregnant women	F 100%	00059 Sexual dysfunction	(00059 DC) Perceived sexual limitation; (00059 DC) Seeks confirmation of desiderability; (00059 DC) Alteration in sexual excitation; (00059 DC) Decrease in sexual desire; (00059 DC) Change in sexual role; (00059 DC) Change in interest towards others; (00059 DC) Change in self-interest
Sanchez-Marin et al. (2008), 2002	Brazil	To identify the nursing diagnosis, according to the taxonomy II of NANDA, about the elder women group considered very pauper	Cross-sectional study	Primary care-women	F 100%	00085 Impaired physical mobility; 00133 Chronic pain; 00098 Impaired home maintenance; 00126 Deficient knowledge; 00078 Ineffective health management; 00054 Risk for loneliness; 00155 Risk for falls; 00137 Chronic sorrow; 00198 Disturbed sleep pattern; 00048 Impaired dentition	unidentified
Montefusco et al. (2011), 2019	Brazil	To study the occurrence of “caregiver role strain” in family members of patients hospitalized for the treatment of chronic diseases	Cross-sectional study	Hospitalization units- family members	Family	00061 Caregiver role strain (female)	(00061 RP) Female caregiver (100% families)
Tiradentes and Quintella Fernandes (2008), 2005	Brazil	To identify the nurses' diagnoses in homeless women, using the domains and classes of the NANDA Taxonomy II	Cross-sectional study	Extra-hospital care - homeless women	F 100%	00078 Ineffective health management; 00048 Impaired dentition; 00011 Constipation; 00002 Imbalanced nutrition: less than body requirements; 00108 Bathing self-care deficit; 00046 Impaired skin integrity; 00146 Anxiety; 000335 Risk for injury	not matching with NANDA
Martins Pereira and Márcia Bachion (2005), 2002	Brazil	To analyse the Nursing Diagnoses identified in low-risk pregnant patients	Cross-sectional study	Hospitalization units- women	F 100%	00004 Risk for infection; 00046 Impaired skin integrity; 00108 Bathing self-care deficit; 00132 Acute pain; 00198 Disturbed sleep pattern; 00092 Activity intolerance; 00017 Stress urinary incontinence; 00126 Deficient knowledge; 00162 Readiness for enhanced health management	(00004 RF) Insufficient knowledge to avoid exposure to pathogens; (00046 RF) Chemical injury agent (00046 DC) Alteration in skin integrity; (00108 DC) Impaired ability to wash body; (00132 RF) Biological injury agent; (00132 DC) Guarding behaviour; (00132 DC) Expressive behaviour; (00198 DC) Feeling unrested; (00092 RF) Imbalance between oxygen supply/demand; (00092 DC) Generalized weakness; (00092 DC) Exertional discomfort; (00017 DC) Involuntary leakage of small volume of urine; (00126 RF) Insufficient information; (00126 DC) Insufficient knowledge; (00162 DC) Expresses desire to enhance choices of daily living for meeting goals
Arcanjo et al. (2006), 2002	Brazil	To analyse the responses of pregnant women pertaining to the sleep and rest class of the activity and rest domain of NANDA ́s Taxonomy	Cross-sectional study	Primary care- pregnant women	F 100%	00096 Sleep deprivation 00198 Disturbed sleep pattern	(00096 DC) Heightened sensitive to pain; (00096 DC) Agitation; (00096 DC) Anxiety; (00096 DC) Decrease in functional ability; (00096 RF) Sustained circadian asynchrony; (00096 RF) Prolonged discomfort (00198 DC) Unintentional awakening; (00198 DC) Difficulty in daily functioning; (00198 RF) Disruption caused by sleep partner
Kocaçal and Karadağ (2020), 2015	Turkey	To determine NANDA-I nursing diagnoses and NIC nursing interventions in patients who underwent radical prostatectomy	Cross-sectional study	Hospitalization units -prostatectomized patients	F 100%	00028 Risk for deficient fluid volume; 00025 Risk for imbalanced fluid volume; 00016 Impaired urinary elimination; 00110 Toileting self-care deficit; 00065 Ineffective sexuality pattern; 00184 Readiness for enhanced decision-making; 00004 Risk for infection; 00206 Risk for bleeding; 000047 Risk for impaired skin integrity; 00214 Impaired comfort	Unidentified
Hamadé et al. (2020), NA	Brazil	To identify nursing diagnoses in coronary patients in the light of Callista Roy's Adaptation Theory	Cross-sectional study	Hospitalization units -coronary patients	M 80% F 20%	Unidentified	Unidentified
Abrão et al. (2005), 2002	Brazil	To identify and validate on clinical setting the DC of the ineffective breastfeeding nursing diagnosis according to NANDA	Cross-sectional study	Outpatient consultations - women in puerperium	F 100%	00104 Ineffective breastfeeding	(00104 DC) Infant arching at breast; (00104 DC) Infant unresponsive to other comfort measures; (00104 DC) Infant inability to latch on to maternal breast correctly; (00104 DC) Infant crying in the first hour after breastfeeding; (00104 DC) Infant resisting latching on to breast; (00104 DC) Insufficient signs of oxytocin release; (00104 DC) Insufficient emptying of each breast per feeding; (00104 DC) Sore nipples persisting beyond first week; (00104 DC) Insufficient infant weight gain
Da Silva Barbalho Braz et al. (2017), 2010	Brazil	To examine the associations between nursing diagnoses, RF and DC of the coping and stress tolerance domain of NANDA in patients with AIDS	Cross-sectional study	Hospitalization units - patients with AIDS	M 72.6% F 27.4%	Unidentified	Unidentified
Da Silva Brandão et al. (2016), 2012	Brazil	To identify the nursing diagnoses in patients with BI	Cross-sectional study	Hospitalization units - patients with BI	M 38.9% F 61.1%	Unidentified	Unidentified
Medeiros-Dantas et al. (2016), 2015	Brazil	To verify the association between nursing diagnoses of physical injury class and its components in critically ill patients	Cross-sectional study	Intensive care units	M 47.7% F 52.3%	Unidentified	Unidentified
De Souza Oliveira-Kumakura et al. (2012), 2008	Brazil	To identify the nursing diagnoses of activity/exercise class among stroke patients	Cross-sectional study	Hospitalization units - patients with stroke	M 52.9% F 47.1%	Unidentified	Unidentified
Sanches Marin et al. (2010), 2002	Brazil	To identify nursing diagnoses, according to NANDA ́s taxonomy II, in a group of older people who use five or more drugs	Cross-sectional study	Primary care- older adults	M 33% F 67%	Unidentified	Unidentified
Mota Guedes et al. (2010), 2007	Brazil	To examine the profile of nursing diagnoses in the activity/rest domain of the II Taxonomy of NANDA-I in hospital admissions of elders	Cross-sectional study	Hospitalization units - older adults	M 75% F 25%	Unidentified	Unidentified
Gonçalves Silva et al. (2015), 2015	Brazil	To identify the NANDA International nursing diagnoses from the terms found in the nursing records of hospitalized children with congenital heart defects and verify the association between these terms and the mapped nursing diagnoses	Cross-sectional study	Hospitalization units - medical records of hospitalized children	M 45.1% F 54.9%	Unidentified	Unidentified
Pessoa Moreira et al. (2010), 2007	Brazil	To analyse the association of the carer's presence to the clients with stroke and the nursing diagnoses for the Activity/ Exercise branch of NANDA-I	Cross-sectional study	Outpatient consultations - patients with stroke	M 52.9% F 47.1%	Unidentified	Unidentified
Lopes et al. (2017), 2015	Brazil	To describe the frequency of nursing diagnoses in hospitalized children	Cross-sectional study	Hospitalization units - children	M 55.1% F 44.9%	Unidentified	Unidentified
Montefusco et al. (2008), 2005	Brazil	To assess the nursing diagnoses of NANDA (2006) identified in families accompanying patients in treatment for non-communicable chronic diseases, by using the Calgary Assessment Model	Cross-sectional study	Hospitalization units - families of patients with chronic diseases	NA	00061 Caregiver role strain (female)	(00061 RP) Female caregiver (100% families)
Alvarez Gomez Matilde et al. (2008), NA	Colombia	To determine the most frequent nursing diagnoses, and the social and clinical profile of 50 young people clinical profile of 50 young people	Cross-sectional study	Extra-hospital care - adolescents addicted to drugs	M 74% F 26%	Unidentified	Unidentified
Ubaldo et al. (2017), 2012	Brazil	To identify nursing diagnoses, their defining characteristics and related factors, according to the NANDA-I (2012–2014)	Cross-sectional study	Hospitalization units - medical records	NA	Unidentified	Unidentified
Dias Araujo et al. (2015), 2012	Brazil	To identify the main nursing diagnoses and interventions described by NANDA and Nursing Intervention Classification for patients with graft-versus-host disease submitted to allogeneic haematopoietic stem cell transplantation	Cross-sectional study	Hospitalization units - patients with graft-versus-host disease submitted to allogeneic haematopoietic stem cell transplantation	M 43% F 57%	Unidentified	Unidentified
Alves Napoleão et al. (2009), 2003	Brazil	To identify the nursing diagnoses in prostatectomized patients with a view to support the elaboration of healthcare plans for hospital discharge	Cross-sectional study	Hospitalization units - prostatectomized patients	M 100%	00126 Deficient knowledge; 00028 Risk for deficient fluid volume; 00035 Risk for injury; 00004 Risk for infection; 00153 Risk for situational low self-esteem; 00068 Readiness for enhanced Spiritual wellbeing; 00146 Anxiety; 00085 Impaired physical mobility; 00100 Delayed surgical recovery; 00152 Risk for powerlessness	(00126 RF) Insufficient knowledge of resources; (00126 DC) Insufficient knowledge; (00028 RF) Insufficient knowledge about fluid needs; (00028 RF) Factors influencing fluid needs; not matching with NANDA; (00004 RF) Alteration in skin integrity; (00004 RF) Insufficient knowledge to avoid exposure to pathogens; (00153 RF) Decrease in control over environment; (00068 DC) Expresses desire to enhance coping; (00068 DC) Expresses desire to enhance participation in religious activity; (00068 DC) Expresses desire to enhance reverence; (00146 RF) Threat to current status; (00146 DC) Irritability; (00085 RF) Decrease in muscle strength; (00085 DC) Alteration in gait; (00100 DC) Evidence of interrupted healing of surgical area; not matching with NANDA
De Oliveira Salgado et al. (2011), 2009	Brazil	To examine the nursing diagnoses labels and actions prescribed by nurses in the clinical records of patients hospitalized in an Adult Intensive Care Unit	Cross-sectional study	Intensive care units - clinical records	M 32% F 68%	00047 Risk for impaired skin integrity (male)	Unidentified
da Silva et al. (2008), 2005	Brazil	To identify the frequency of the main nursing diagnoses according to the NANDA in male patients admitted at an orthopaedic yard	Cross-sectional study	Hospitalization units - patient orthopaedic yard	M 100%	00085 Impaired physical mobility; 00091 Impaired bed mobility; 00090 Impaired transfer ability; 00088 Impaired walking; 00108 Bathing self-care deficit; 00109 Dressing self-care deficit; 00102 Feeding self-care deficit; 00110 Toileting self-care deficit; 00004 Risk for infection; 00093 Impaired skin integrity; 00044 Impaired tissue integrity	Unidentified
Mota Guedes et al. (2009), 2005	Brazil	To analyse the nursing diagnosis profile of the domain Security/ Protection, of NANDA Taxonomy II, in the hospital admission of elderlies	Cross-sectional study	Hospitalization units – older adults	M 75% F 25%	Unidentified	Unidentified
Vieira, Bachion, Coelho, et al. (2010), 2009	Brazil	To analyse the occurrence of nursing diagnosis Anxiety, in puerperal women immediately after and in the later period, in a community context	Cross-sectional study	Primary care- puerperal women	F 100%	00146 Anxiety	(00146 RF) Stressors; (00146 RF) Maturational crisis; (00146 DC) Worried about change in life event; (00146 DC) Insomnia
Neves Inácio et al. (2010), 2007	Brazil	To identify the Nursing Diagnoses according to the taxonomy NANDA II 2007/2008, in newborns, and to describe the facts related to it and the risk factors	Cross-sectional study	Hospitalization units - newborns	M 68.6% F 31.4%	Unidentified	Unidentified
Castro Sampaio et al. (2017), 2015	Brazil	To identify the profile of nursing diagnoses in people with hypertension and diabetes in primary health care	Cross-sectional study	Primary care- people with hypertension and diabetes	M 33.1% F 66.9%	Unidentified	Unidentified
Tamboril et al. (2015), 2012	Brazil	To analyse the accuracy of DC of the nursing diagnosis “Deficient Knowledge” in users of combined oral contraceptive	Cross-sectional study	Primary care- women users of COC	F 100%	00126 Deficient knowledge	(00126 DC) Inaccurate follow-through of instruction; (00126 DC) Inappropriate behaviour; (00126 RF) Insufficient interest in learning; (00126 RF) Misinformation presented by others
Dos Santos et al. (2009), 2005	Brazil	To analyse the profile of the nursing diagnosis of the Health Promotion Domain of NANDA	Cross-sectional study	Hospitalization units – older adults in discharge process	NA	Unidentified	Unidentified
Vieira et al. (2011), 2009	Brazil	To analyse the occurrence of nursing diagnoses related to breastfeeding in the immediate postpartum in the context of the community	Cross-sectional study	Primary care-postpartum women	F 100%	00104 Ineffective breastfeeding; Effective breastfeeding; Risk for Ineffective breastfeeding	(00104 RF) Supplemental feedings with artificial nipple; (00104 RF) Insufficient family support; (00104 RF) Maternal anxiety; (00104 RF) Maternal breast anomaly; (00104 RF) Interrupted breastfeeding; (00104 RF) Poor infant sucking reflex; (00104 DC) Perceived inadequate milk supply; (00104 DC) Insufficient emptying of each breast per feeding; (00104 DC) Unsustained suckling at the breast NA in NANDA-I currently; NA in NANDA-I currently

Abbreviations: AIDS, Acquired Immunodeficiency Syndrome; BI, bullous immunodermatosis; COC, combined oral contraceptive; DC, Defining Characteristics; F, Female; M, Male; NA, not available; RF, Related Factors.

4.2 Gender analysis

When focusing on the identification of the gender of the participants, which is the first step to applying a gender approach, in the articles selected for this review we observe that in four articles (10% of the total), the percentage of women, men or other gender categories in the sample were not identified. With regard to the three parts that are included in the diagnostic formulation (diagnostic label, defining characteristics or related factors), 20 articles did not identify the gender of the participants in any of these parts. All the results of this section are synthesized in Table 3.

TABLE 3. Characteristics of studies including nursing diagnoses with gender perspective

Author (publication year), Nanda edition	Country	Objective	Methods	Clinical field/population	Sample gender	Nursing diagnoses gender identification	DC and RF gender identification
Albert-Sobrino et al. (2005), 2003	Spain	To determine how a group of adolescents perceive their body image from a nursing perspective	Cross-sectional study	School- teenagers	M 46.7% F 53.3%	00053 Social isolation (female); 00120 Situational low self-esteem (female)	unidentified
de Carvalho-Medeiros et al. (2010), 2009	Brazil	To determine the occurrence of the DC of nutritional nursing diagnoses, verifying the association between the DC and the variables: gender, age, weight and height	Cross-sectional study	School- children	M 42.1% F 57.9%	00163 Readiness for enhanced nutrition (female); 00002 Imbalanced nutrition: less than body requirements (male)	(00163 DC) Expresses desire to enhance nutrition (female); (00002 DC) Pale mucous membranes (male)
Montefusco et al. (2011), 2019	Brazil	To study the occurrence of “caregiver role strain” in family members of patients hospitalized for the treatment of chronic diseases	Cross-sectional study	Hospitalization units- family members	12 families	00061 Caregiver role strain (female)	(00061 RP) Female caregiver (100% families)
Montefusco et al. (2008), 2005	Brazil	To assess the nursing diagnoses of NANDA (2006) identified in families accompanying patients in treatment for non-communicable chronic diseases, by using the Calgary Assessment Model	Cross-sectional study	Hospitalization units - families of patients with chronic diseases	NA	00061 Caregiver role strain (female)	(00061 RP) Female caregiver (100% families)

Abbreviations: DC, Defining Characteristics; F, Female; M, Male; NA, not available; RF, Related Factors.

The following results are summarized following the different parts in the formulation of a nursing diagnoses in the NANDA-I taxonomy: diagnostic label (DL); defining characteristics (DC) and related factors (RF).

4.2.1 Nursing diagnostic labels with a gender perspective

Four articles conducted an in-depth analysis considering the gender perspective (Table 3), which included describing gender (women and men) in the DL and in their corresponding DC and FR. No other gender approaches were described in any of the articles included.

One article, which aimed to determine how a group of adolescents perceived their body image from a nurse's perspective, identified DLs 00053 Social isolation and 00120 Situational low self-esteem as more prevalent in girls. However, no DC and associated RF were described (Albert-Sobrino et al., 2005).

Two studies identified DLs in family members of patients hospitalized for the treatment of chronic diseases and identified DL 00061 Caregiver role strain. This DL was present in all female caregivers and described female caregivers as a population at risk, as reflected in the NANDA-I taxonomy (Montefusco et al., 2008, 2011).

Finally, a fourth article aimed to determine the occurrence of the defining DC of nutritional nursing diagnoses, verifying the association between the DC and the variables gender, age, weight and height (de Carvalho-Medeiros et al., 2010). The study identified that DL 00163 Readiness for enhanced nutrition and the DC (00163 DC) Expresses desire to enhance nutrition are more common in girls. In addition, DL 00002 Imbalanced nutrition: less than body requirements and DC (00002 DC) Pale mucous membranes are more common in boys.

4.2.2 Most frequent nursing diagnostic labels in women

Of the 38 selected articles, 13 identified that diagnostic labels occur in women; nine of them because they were studies about women's sexual and reproductive health (Abrão et al., 2005; Arcanjo et al., 2006; Assunção Queiroz et al., 2013; Martins Pereira & Márcia Bachion, 2005; Tamboril et al., 2015; Vieira et al., 2011; Vieira, Bachion, Coelho, et al., 2010; Vieira, Bachion, Marques Salge, et al., 2010; Xavier De Lemos et al., 2012), and the remaining four because the sample was female (de Oliveira Alexandre et al., 2017; Fernandes dos Santos Lima et al., 2012; Sanchez-Marin et al., 2008; Tiradentes & Quintella Fernandes, 2008).

In terms of DLs, 27 were identified in articles focusing on sexual and reproductive health; the most frequent were: 00104 Ineffective breastfeeding (identified in four articles); 00046 Impaired skin integrity and 00126 Deficient knowledge (identified in three articles); and 00004 Risk for infection, 00132 Acute pain, 00146 Anxiety, 00153 Risk for situational low self-esteem, 00198 Disturbed sleep pattern, and 00227 Risk for ineffective childbearing process (identified in two articles).

4.2.3 Defining characteristics and related factors in women

If we focus on the DC and RF of the most frequent diagnoses identified in the different articles, we observe that in two (Sanchez-Marin et al., 2008; Vieira, Bachion, Coelho, et al., 2010; Vieira, Bachion, Marques Salge, et al., 2010), they were not identified, and in two articles (Tiradentes & Quintella Fernandes, 2008; Xavier De Lemos et al., 2012), the identified DC and RF did not coincide with those included in the NANDA-I taxonomy.

The DCs identified for DL 00104 Ineffective breastfeeding were: (00104DC) Insufficient signs of oxytocin release, (00104 DC) Sore nipples persisting beyond first week, and (00104 DC) Perceived inadequate milk supply. The RFs were: (00104 RF) Supplemental feedings with artificial nipple, (00104 RF) Insufficient family support, (00104 RF) Maternal anxiety, (00104 RF) Maternal breast anomaly and (00104 RF) Interrupted breastfeeding.

The identified DCs for DL 00046 Impaired skin integrity were (00046 DC) Alteration in skin integrity and RF (00046 RF) Chemical injury agent.

For DL 00126 Deficient knowledge, DC (00126 DC) Inappropriate behaviour and (00126 DC) Inaccurate follow-through of instruction, the RFs were (00126 RF) Insufficient information, (00126 RF) Insufficient interest in learning and (00126 RF) Misinformation presented by others.

For DL 00004 Risk for infection, only RF (00004 RF) Insufficient knowledge to avoid exposure to pathogens was identified.

For DL 00132 Acute pain, the RF (00132 RF) Biological injury agent and DCs (00132 DC) Guarding behaviour and (00132 DC) Expressive behaviour were identified.

For DL 00146 Anxiety, the DCs (00146 DC) Worried about change in life event and (00146 DC) Insomnia and the RFs (00146 RF) Stressors and (00146 RF) Maturational crisis were described.

The identified DCs for 00198 Disturbed sleep pattern were (00198 DC) Feeling unrested, (00198 DC) Unintentional awakening, and (00198 DC) Difficulty in daily functioning. The RF identified was (00198 RF) Disruption caused by sleep partner.

Finally, for DL 00153 Risk for situational low self-esteem and 00227 Risk for ineffective childbearing process, the DC and RF were not identified or did not belong to the NANDA-I taxonomy.

4.2.4 Most frequent nursing diagnostic labels in men

Only three studies (Alves Napoleão et al., 2009; da Silva et al., 2008; Kocaçal & Karadağ, 2020) determined gender by the context in which they were carried out. In two of them, the aim was to identify the nursing diagnoses in prostatectomized patients, and the third aimed to identify the frequency of the main nursing diagnoses in male patients admitted to an orthopaedic ward. In studies focusing on patients undergoing a prostatectomy, only 00004 Risk for infection and 00028 Risk for deficient fluid volume were present in both.

4.3 Quality assessment

The quality of the studies included was analysed following the criteria of the MMAT tool.

In general, studies did not fulfil all the quality criteria described in the MMAT instrument. Many of the studies did not report any data on risk of non-response bias or the sampling strategy. In some cases, data were missing concerning the statistical analysis that followed (Appendix S1).

5 DISCUSSION

To the best of our knowledge, this is the first systematic review to collate and analyse the use of NANDA-I nursing diagnoses from a gender perspective.

In this study, the most frequent DL contained in the NANDA-I taxonomy published in the scientific literature for women and men have been identified and also the description of DC and RF on the use of the DL in women and men has been considered. Overall, most selected articles identified the gender (in binary form: women and men) of the participants for the inclusion of their samples, but only 20 considered gender in the DL. Additionally, there was scarce identification of the different RFs and DCs for women and men in most of the studies reviewed. No other gender approaches were described in any of the articles included. These findings suggest the existence of gender biases in the studies that describe NANDA-I diagnoses applied to care plans. Previous research has already shown that biases in diagnostic and therapeutic efforts (Moreno Campoy et al., 2015; Westergaard et al., 2019) can lead health professionals, and nurses in particular, not to respond to the real needs of people and communities (Sutherland et al., 2017). Additionally, it is essential to evince and understand differences and gender to take them into account in order to design effective and equitable nursing interventions (Felzmann, 2020).

Moreover, the failure to identify gender upon diagnosis is important if we consider that the current scientific evidence and theories concerning both the improvement in humanistic and evidence-centred health care (Doyal, 2001; Varcoe et al., 2008) and policy recommendations to combat gender inequalities (Hay et al., 2019) are committed to identifying these [gender] specificities that may prove decisive for people's health outcomes (Law & Gustafson, 2017; Pucci et al., 2017).

According to our results, of the four studies in which diagnosis included identification by gender, two focused exclusively on the exposure of the highest frequency in women (Albert-Sobrino et al., 2005; de Carvalho-Medeiros et al., 2010), but did not consider the implication of what this difference means for them. Evidence shows that a gender approach in research includes, as a first step, the disaggregation of data by sex, but also the implication of the factors that determine inequality between women and men. Additionally, the characteristics that contribute to these differences can produce inequalities or a lack of opportunities for some individuals in relation to others (Heidari et al., 2016; Tomás et al., 2015). In this sense, the communication of the European Commission of 1999, Women and Science: mobilizing women to enrich European research, established two objectives for the European approach to gender mainstreaming in research: to increase the presence of women at all levels and stages of research and to integrate the gender dimension in research (Commission of the European Communities, 1999). This implies conducting studies that undertake separate analysis of the data based on sex and gender, and conducting research specifically on gender to fill existing knowledge gaps (Commission of the European Communities, 1999; Hammarström & Hensing, 2018; Johnson et al., 2009).

When analysing more specifically the type of diagnoses chosen by some authors, two articles (Montefusco et al., 2008, 2011) identify the label (00061) Tiredness of the caregiver role as being more frequent among women. Although the NANDA-I taxonomy identifies women caregivers as a population at risk, the word “caregiver” is kept masculine on the label (i.e. in the Spanish translation of the NANDA-I taxonomy). The use of sexist language occurs in some translations of the taxonomy that have masculine and feminine nouns, as opposed to the English language in which caregiver is a neutral concept. Consequently, it would be important that the NANDA-I taxonomy itself should establish the use of non-sexist language as a requirement in the translations of its terminology, as has already been done by various scientific societies related to health (Bates et al., 2018; Bevan & Learmonth, 2013; Nieuwenhoven & Klinge, 2010).

In this review, we identified a single article in which the existence of differential morbidity and the different diagnostic implications in the evaluation of the characteristics of the diagnoses was made explicit, in this case in situations related to nutrition in girls and boys (de Carvalho-Medeiros et al., 2010). This is the only piece of research that can respond to the second and third objectives of our study, which highlights the scant application of the gender perspective in the use of NANDA-I terminology.

Furthermore, our study also shows that more than half of the healthcare settings in which the research is carried out are related to community care whose starting points and priority areas of nursing interventions are lifestyles, health management and individual behaviours. The existing scientific evidence demonstrates how gender, which intersects with other dimensions such as social class and culture (Celik et al., 2011; Hankivsky, 2012; Ryan & El Ayadi, 2020), determines the health-disease-care process and that, therefore, no contemplating this approach from the primary care level perpetuates the existence of health inequalities (Carratala-Munuera et al., 2021; Delgado et al., 2016; Ricci-Cabello et al., 2010; Taylor & Green, 2008).

In terms of the consideration of a biopsychosocial approach, which facilitates the vision of the individuals as a whole and the consideration of the gender perspective, as shown in Table 2, most of the diagnoses focus on biomedical labels (69 out of 91). In particular, of the 48 identified in women, 19 correspond to biomedical terms, and in the 12 DL identified in men, six also consider a biomedical approach. Our review also shows how diagnoses related to maternity processes are focused on biomedical aspects and, as some authors have pointed out, leave aside the experiences of women about processes related to maternity (Bacigalupe et al., 2020; Rodríguez Mir & Martínez Gandolfi, 2021). This perspective situates women in a subordinate position (which has already been the object of criticism in various studies) of a social and cultural nature related to health (Esteban, 2016; Pombo, 2012). The negative effects of this victimization of women in nursing research are also observed in healthcare practice and in education, creating a discourse that perpetuates the invisibility of specific health states of women beyond reproductive processes and an androcentric model of health sciences (Morris et al., 2020).

Moreover, current trends that reflect on the paths to follow in order to move the nursing discipline forward and its implication in society highlight the need to include poststructuralism in research programs, clinical settings and in overall nursing knowledge creation (Holmes & Gagnon, 2018).

The conceptualizations of biopolitics and biopower (Foucault, 1991, 2007) tell us of forms of control and domination based on social discourses about scientific knowledge, considering it neutral, unique and invariable and indicate the need for rethinking the conceptual bases of health sciences and nursing. Following these ideas, it is essential to adapt nursing terminology to describe the differences and the wealth of the diversity of the populations receiving nursing care (Lee et al., 2019; Pedersen et al., 2012; Sommer et al., 2019). In this regard, critical discourses of appropriation of these control mechanisms exist, which point to the transgression or change of biotechnologies and question the impositions of the sex–gender system (Esteban, 2007; Haraway, 1999).

Based on our research, the current state of the scientific literature describing the use of nursing diagnoses and its lack of gender perspective has been highlighted and its potential impact and implications for clinical practice, individuals, society and the nursing profession. In this sense, it is essential to continue promoting the gender perspective as a central value in the research of the NANDA-I taxonomy (Gunn et al., 2019; Vuolanto & Laiho, 2017). In the application of the NANDA-I taxonomy, gender should be included as a principal category and variable, considering the different social phenomena and their differential repercussions for both women and men (Ariño et al., 2011).

5.1 Limitations

The present study has limitations inherent to a systematic review. In addition, it should be noted that in the articles selected for this review, the latest editions of the NANDA-I taxonomy (in relation to the year of publication of the study) are not used for the identification of LD meaning that possible changes are not reflected in the corresponding edition. Moreover, the fact that most of the selected studies were carried out in Brazil makes generalization difficult at a cross-cultural level.

However, this study has notable strengths. It is the first known study that specifically analyses the existence of gender biases in the use of NANDA-I nursing diagnoses in nursing publications, especially considering how differences and inequalities derived from the sex structure determine the causes and manifestations of clinical judgements applied in nursing care.

6 CONCLUSIONS

Based on the analysed articles, gender perspective is not systematically incorporated in the use of the NANDA-I taxonomy. Therefore, gender biases in the use of NANDA-I diagnoses exist. This situation poses barriers to the application of the existing scientific evidence about the differences between women and men in health-disease processes, and the factors and clinical manifestations that determine the health responses that are different and unequal between women and men.

The failure to incorporate a gender approach in the diagnostic formulation in the DL, RF and DC can erroneously lead to the design of care plans with inadequate responses and that are not adapted to the realities of the health determinants of women and men.

In some translations of the taxonomy into languages that have masculine and feminine nouns, a sexist language is used, which highlights the need for the NANDA-I Association itself to require the non-sexist use of language in the translations of its terminology. To move forward, considering the evidence on the existence of gender biases in the use of NANDA-I taxonomy, we should identify the specific aspects that must be considered in order to analyse each of its diagnoses integrating gender relations and roles with a perspective beyond binarism.

AUTHOR CONTRIBUTIONS

All authors have collaborated on the final version of the manuscript. Their collaboration has been developed as follows: RR, MR, AP have had an essential role in the conception and design of the study; RR, MR, AP, LB collected the data; RR, MR, AG analysed and interpreted the data with critical revision/perspective of its scientific content; RR, MR, AG, EC prepared and wrote the manuscript; All authors approved the final version of the manuscript for submission.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
drafting the article or revising it critically for important intellectual content.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

Open Research

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Supporting Information

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Volume10, Issue3

March 2023

Pages 1305-1326

Analysis of gender perspective in the use of NANDA-I nursing diagnoses: A systematic review

Abstract