Recently, we received a question on one of our social media platforms:
“Numerous authors brought Standardized Nursing Languages (mainly NNN) forward in practice, science and research. Reinventing the wheel (by renaming(s), e.g. NANDA to INKA (etc.) doesn’t seem an effective strategy for trustful collaboration. Can this bring the nursing community together?”
We want to take this opportunity to respond thoughtfully, and with a little more detail than seems appropriate for a social media exchange.
We have great respect for the many scholars who have advanced, and who continue to advance, standardized nursing languages, including the substantial body of work involving NANDA-I, NIC, and NOC. NANDA 360 does not disregard that history, nor does it merely rename what came before; it builds upon what has been learned through decades of research, implementation, and, especially importantly, feedback from nurses attempting to use these systems in practice and education.
Science requires us to remain open to evidence, including evidence that an approach may not be working as consistently or effectively as intended. Over many years, we have heard repeatedly from users around the world that linking NANDA-I, NIC, and NOC (NNN) in a consistent and reproducible manner can be difficult. There are certainly organizations and researchers who have implemented NNN thoughtfully and successfully, and their work deserves recognition. Examples of these successes can be found in the published nursing literature, including our own journal, The International Journal of Nursing Knowledge.
However, this has not been the experience reported by the largest proportion of our users. We have observed a significant decline internationally in the use of all three classifications together worldwide, with many organizations telling us that they continue to use NANDA-I nursing diagnoses, or a combination of NANDA-I and NIC, while many others are developing or adopting their own interventions and/or outcomes.
In many settings, this has resulted in standardized care plans in which essentially the same interventions and outcomes are linked to every patient with a particular nursing diagnosis. Nurses have expressed frustration with approaches that insufficiently reflect individual assessment data, but many organizations lack the nursing time and/or knowledge, informatics resources, or technical infrastructure required to create a more sophisticated integration of assessment, diagnosis, nursing actions, and outcomes. Integrating three independently developed classifications within an electronic health record can itself present significant challenges. For years, users have asked us for greater support in creating a more integrated approach.
We have heard similar concerns from nursing education. Faculty members tell us that students can struggle to understand the relationships among three separate classifications and, more importantly, to understand how standardized nursing language represents nursing knowledge rather than simply a documentation requirement. We are frequently asked by nursing faculty, particularly those who are newer to teaching, how clinical reasoning, standardized nursing language, and the nursing process can be integrated meaningfully throughout the curriculum. A particular challenge is making the evidence supporting linkages among assessment findings, diagnoses, interventions, and outcomes visible and understandable to students. Different textbooks and care-planning resources also approach these linkages differently, which contributes to inconsistency in how students learn to connect assessment data with clinical decisions. These concerns are not criticisms of individual educators; rather, they point to an opportunity to provide educators and students with a more coherent and transparent framework.
A major concern, therefore, is not simply whether linkages can be created, but how they are created. Under the traditional NNN approach, each organization is effectively responsible for developing its own linkages. Some organizations link interventions and outcomes directly to the diagnostic label, an approach we do not support because patients with the same diagnosis often do not have the same assessment findings, etiologies, priorities, goals, or care needs. Other organizations have developed much more sophisticated approaches that incorporate assessment data, defining characteristics, related factors, or risk factors. These efforts are thoughtful and require substantial investments of nursing time and expertise. Yet when the resulting linkages differ from organization to organization, the meaning of the resulting data also differs across settings. That limits our ability to aggregate nursing data, compare outcomes across organizations, identify which interventions are most effective for which patients under which circumstances, and ultimately advance nursing science. Local innovation may improve care within an individual organization, but without greater consistency it cannot fully realize the potential of standardized nursing knowledge at the system, national, or international level.
NANDA 360 was developed specifically in response to these concerns. The Board deliberately commissioned individuals with expertise in research methodology, standardized nursing language, nursing science application, and the advancement of research in this field. Those involved in its development had no financial or professional stake in electronic health record products, textbooks, royalties, workshop revenue, or other commercial products that might benefit from a particular outcome. This was critical because we wanted science to lead the way. The intent was to answer a fundamental question: Based on what we have learned from research and user implementation, can we create a more integrated, assessment-driven, and evidence-based approach that enables nursing knowledge and nursing data to be used more consistently across settings?
NANDA 360 should, of course, be critically evaluated. We expect debate. Some will strongly support the approach; some will be interested but appropriately skeptical; and others may prefer approaches they already know and use successfully. That diversity of perspectives is part of scientific discourse, and we welcome it. At the same time, rigorous scientific critique requires an opportunity to examine a model, its methodology, its supporting evidence, and its intended use before drawing conclusions about its value. NANDA 360 is only now beginning to be presented more broadly, and we encourage the nursing community to examine it, question it, test it, and contribute to its continued development once it is released with our 14th edition publication. If critiqued scientifically, it will become clear that NANDA 360 is not a renaming of NNN – it is a new concept altogether.
It is also important to distinguish NANDA 360 from the association’s name change. The decision to move beyond the name NANDA International was neither recent nor a response to NANDA 360. Members voted on this direction in 2016, with more than 80% supporting the change. The rationale was that the work of the association had already expanded beyond the narrower boundaries suggested by an association name centered exclusively on nursing diagnosis. Our work, and the themes in our journal and our conferences, increasingly addressed the creation of nursing knowledge along with assessment, clinical reasoning, and the nursing process. The title of our journal was subsequently changed to reflect that wider scientific focus. After approximately a decade of deliberate movement toward this vision, the association name has now changed to the International Nursing Knowledge Association (INKA). The change therefore represents an evolution in the association’s mission rather than simply a renaming of NANDA-I.
We have been encouraged by the response from individuals outside what might traditionally have been considered the “NANDA-I sphere.” Many have welcomed a broader vision for an association focused not only on nursing diagnoses, but on the development, organization, testing, and use of nursing knowledge more broadly. That does not diminish the importance of nursing diagnosis. Rather, it recognizes that diagnosis exists within a much larger process of assessment, clinical reasoning, nursing action, outcome evaluation, and knowledge development.
Ultimately, bringing the nursing community together does not require preserving existing structures simply because they are familiar, nor does it require everyone to agree with every new direction. It requires respect for the scholarship that brought us to this point, openness to what we have learned from implementation, and a willingness to respond when nurses, educators, researchers, and organizations tell us that existing approaches are not fully meeting their needs.
Our shared responsibility is to continue asking how nursing knowledge can become more scientifically robust, clinically meaningful, interoperable, and useful across organizations and countries, and to remain willing to evolve when evidence and experience suggest that we can do better.
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