Journal of Transcultural Nursing

http://tcn.sagepub.com/ ''Does One Size Fit All?'' Exploring the Cultural Applicability of NANDA Nursing Diagnoses to Chinese Nursing Practice
Wei-Shu Lai, Co-Shi Chantal Chao, Wan-Ping Yang, Hsiao-Ching Liu and Ching-Huey Chen J Transcult Nurs 2013 24: 43 originally published online 16 October 2012 DOI: 10.1177/1043659612462403 The online version of this article can be found at: http://tcn.sagepub.com/content/24/1/43

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462403
03Journal of Transcultural NursingLai et al.

TCNXXX10.1177/10436596124624

Research Department

Does One Size Fit All? Exploring the Cultural Applicability of NANDA Nursing Diagnoses to Chinese Nursing Practice

Journal of Transcultural Nursing 24(1) 4350 The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659612462403 http://tcn.sagepub.com

Wei-Shu Lai, PhD, RN1,2, Co-Shi Chantal Chao, PhD, RN1, Wan-Ping Yang, PhD, RN1, Hsiao-Ching Liu, MSN, RN1, and Ching-Huey Chen, PhD, RN1

Abstract East Asia has historically unique concepts of health and well-being and thus is an appropriate setting for exploring the multicultural applicability of the North American Nursing Diagnosis Associations Nursing Diagnoses (NANDA ND) system. This study aimed to explore how NANDA ND affect the growth and quality of professional nursing from the perspective of Taiwanese nurses. Grounded theory was employed in this interview-based investigation of 53 Taiwan-licensed nursing professionals at various hospitals in Taiwan. Data were analyzed using constant comparative analysis until theoretical saturation was reached. The core concept, Struggling with (the NANDA ND notion that) One Size Fits All, emerged after ongoing analysis of the effects of NANDA ND on good nursing, patient welfare, and professional development. The preliminary theoretical framework developed from this study provides evidence that NANDA ND may be incompatible with the cultural beliefs of the traditional Chinese health care setting in Taiwan, which emphasize holistic harmony and balance. Keywords nursing diagnoses, NANDA, Chinese culture, Taiwanese nurses, grounded theory, good nursing, professional growth

Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA International, 2010). Nursing diagnoses (ND) attempt to standardize terminology for nurse-accountable diagnoses, interventions, and outcomes (Gebbie & Lavin, 1975; Hiraki, 1992). Increasing worldwide interest by 2002 resulted in NANDA (North American Nursing Diagnosis Association) International (NANDA-I), with approximately 207 ND approved for clinical testing and refinement (NANDA-I, 2010). ND in computerized patient records/software allow digital nursing care documentation (Gordon, 1998; Hogston, 1997). ND were regarded as a tool for optimizing patient diagnosis and management (Edel, 1982). Most previous research focused on clinical validation of ND (Galdeano, Rossi, & Pelegrino, 2008; Hardiker & Rector, 2001; Neusa, Tania, & Hussein, 2008; Wieseke, Twibell, Bennett, Marine, & Schoger, 1994). However, the cultural applicability of North Americanbased NANDA ND evoked debate in Europe, for example, U.K. nurses reported ND as incompatible with traditional U.K. nursing (Hogston, 1997). NANDA-I is intended for global use, but the cultural applicability and relevance of NANDA ND in East Asia, with historically unique concepts of health and well-being, have received little attention.

Traditional Chinese medicine (TCM) is a common part of medical care throughout East Asia. TCM doctrines are rooted in cosmological notions such as the yin-yang concept. The eight hexigrams (Bagua) of the traditional expanded yin/ yang (line patterns surrounding yin-yang in the center of Figure 1) are axiomatic in Chinese culture and logic (Chiang & Lu, 1996; Ebrey, 1993) but are alien to Western thinking. The solid yang and dotted yin lines coexist and help express the constant intertransformation and dynamic equilibrium of the various elements. Health is seen as harmonious interaction of the entities and the outside world, whereas disease is interpreted as interactive disharmony. Inherent cultural values can significantly affect ones perception of good nursing. The Taiwan Nursing Accreditation Council (TNAC) describes eight core professional nursing competencies: critical thinking, general clinical nursing
1 2

National Cheng-Kung University, Tainan, Taiwan Meiho University, Pingtung, Taiwan

Corresponding Author: Co-Shi Chantal Chao, Institute of Allied Health Sciences, College of Medicine, National Cheng-Kung University, No. 1, University Road, Tainan 70101, Taiwan Email: chantal@mail.ncku.edu.tw

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Journal of T ranscultural Nursing 24(1)

Figure 1. Preliminary theoretical framework of applicability of NANDA ND from the perspective of TCM-influenced Taiwanese nurses
Note: TCM = traditional Chinese medicine.

skills, basic biomedical science, communication and team work capabilities, caring, ethics, accountability, and lifelong learning. These competencies are supported by Chang, Yu, and Chens (2007) study of good nursing practice in East Asia and in Taiwan and are believed to ensure good nursing education, good nursing, and the essential elements of professional development. Perception of good nursing is presumably influenced by local cultural attitudes. Global application of ND must consider implementation within different cultural contexts. How useful are NANDA ND in health care systems that differ from North America? Our study addressed this question by interviewing nursing professionals in Taiwan. As a country with a highly modernized health care system but with significant TCM influence, Taiwan is thus an excellent test site for evaluating the utility of NANDA ND in contemporary East Asia.

Method Design
Grounded theory (GT) was used to explore Taiwanese nurses perspectives on the use of NANDA ND regarding the quality and professional development of nursing. GT serves as an appropriate means of elucidating data pertaining to cultural factors when little prior inquiry exists (Glaser, 1992; Speziale & Carpenter, 2003; Subgranon & Lund, 2000). Constant comparative analysis was carried out during data collection and analysis to develop a theoretical framework using empirical data.

Sampling and Settings

This study was approved by the ethics committee of the university overseeing the project. After institutional review

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Lai et al. board approval, licensed nursing personnel were interviewed after written informed consents were obtained. This was the first study of its kind in the Taiwanese professional nursing community. Because of a lack of data in the literature, purposive sampling was used at the beginning of the study, followed by theoretical sampling during analysis (Burns & Grove, 2001; Chiovitti & Piran, 2003; Strauss, 1987). To obtain a comprehensive overview, interviewees were selected across a range of clinical positions, from junior to senior nursing staff. Data saturation was achieved with 53 participants. Nursing professionals working in 32 hospitals from 13 (59%) of Taiwans provinces were invited to participate. Six participants (11%) were from rural hospitals, whereas 47 participants (89%) were from urban facilities. Participant demographic characteristics are outlined in Table 1. All participants had trained in NANDA ND, that is, their curricula used ND concepts or practical programs using NANDA ND to record nursing care. Fortysix (87%) had used NANDA ND in a clinical setting; 31 (58%) had supervised new nursing staff or students, which included the use of NANDA ND during practical training (Table 1).

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Table 1. Demographic Characteristics of Participants and Their Experience With NANDA ND (N = 53) Characteristics Mean (SD) n (%)

Instrument
Table 2 outlines the investigator-developed interview guide, which was based on the TNAC core professional competencies (Chao, 2004; TNAC, 2011). The final question allowed perspectives beyond the scope of TNAC predefined core competencies to be discovered. These questions were asked to all participants, in the same order. An extra question was designed for participants who studied NANDA ND during their formal education but did not use NANDA ND in their clinical setting: Could you tell me about why you did not use NANDA ND in your clinical practice? Each participant provided an in-depth and detailed description of their views. All interviews were conducted by the authors in the Mandarin dialect of the Chinese language. All participants and investigators were highly conversant in the dialect. All interviews were recorded and transcribed. In accordance with GT principles, interview questions were further refined by data from previous interviews (Strauss & Corbin, 1994). For example, several participants said, NANDA ND provide novices with guidelines containing defining characteristics and related factors to fit patient conditions, which was encoded as gives novice nurses guidelines to follow and fitting ND (matching ND to patient conditions). Consequently, the interview guide questions became restated as follows: What are the effects of NANDA ND on professional growth from novice to expert? How does fitting NANDA ND affect your day-to-day practice? What are the effects of fitting ND on the quality of nursing care? Probing follow-up questions encouraged participants to elaborate.

Age (years) 39 (7.2) 30-40 37 (70%) 41-50 12 (22%) 51-60 4 (8%) Gender Male 0 (0%) Female 53 (100%) Hospital level of workplace Medical centers (800-2,500 beds) 22 (41%) Regional hospitals (300-800 beds) 28 (53%) Local hospitals (20-300 beds) 3 (6%) Hospital location of workplace Urban 47 (89%) Rural 6 (11%) Clinical experience (years) 14.3 (7.9) 1-5 3 (6%) 6-10 16 (30%) 11-15 16 (30%) 16-20 9 (17%) >20 9 (17%) Highest level of education completed Junior college 4 (7%) University 36 (68%) Masters 13 (25%) Current position 34 (64%) Clinical staff nurse Head nurse 16 (30%) Supervisor 3 (6%) Received training in use of NANDA ND Yes 53 (100%) No 0 (0%) Have used NANDA ND in clinical experience Yes 46 (87%) No 7 (13%) Have supervised new nurses or students at practical NANDA ND? Yes 31 (58%) No 22 (42%)
Note: NANDA ND = North American Nursing Diagnosis Associations Nursing Diagnoses.

Data Collection and Analysis

Data collection was consistent with GT principles. Theoretical sampling guided data collection. In-depth interviews lasted

60 to 90 minutes. Open-ended questions with simultaneous data collection and analysis produced an emergent design (Chiovitti & Piran, 2003; Strauss & Corbin, 1990, 1994). Initial analysis identified meaning units, which were condensed to clarify content, labeled using an open code and grouped thematically into categories. Constant comparisons were made within and between categories with regard to repeated and new content (Struass & Corbin, 1990; Wiitavaara, Barnekow-Bergkvist, & Brulin, 2007). Emerging core and related conceptual groups helped focus the interviews (Strauss & Corbin, 1990). The process ended when

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Table 2. Interview Guide: Questions Asked to All Participants

Journal of T ranscultural Nursing 24(1)

1. Could you tell me about your experience using NANDA ND in your clinical practice? 2. How does NANDA ND influence your professional nursing regarding problem solving, critical thinking, ethical sensitivity, and lifelong learning? 3. How does NANDA ND influence your communication and cooperation with other professionals in the health care team? 4. What is your experience using NANDA ND with regard to integrating basic biomedical science and general clinical nursing skills during clinical care? 5.What is your experience using NANDA ND to provide individual, holistic, and continuous care? 6. In your point of view, what are the strengths and weaknesses of NANDA ND in clinical practice? 7. Overall, what are your opinions of NANDA ND? 8. Is there anything else you would like to say or expand on?
Note: NANDA ND = North American Nursing Diagnosis Associations Nursing Diagnoses.

theoretical saturation was reached and further interview yielded no new information. It then became possible to describe the emerging categories and draw comparisons between them, whereupon a theoretical framework was formulated. Researchers were required to reflect on their own perspectives toward the subject matter to help minimize potential bias in data collection and analysis (Chiovitti & Piran, 2003). To increase data credibility, a randomly chosen 30% of participants reviewed and confirmed interview findings (Lincoln & Guba, 1985; Padgett, 2008). All authors had experience in qualitative research, nursing education, and clinical practice. Regular team meetings facilitated interview analysis and resulting code formulation (Wiitavaara et al., 2007). Theoretical memos established an audit trail to help theory formation and the tracking of thinking (Holloway & Wheeler, 2002; Lincoln & Guba, 1985).

to the struggle of simplifying complicated symptoms and human illness in order to fit NANDA ND. One interviewee mentioned recording terminal cancer pain via NANDA ND: Pain problems require an overall assessment of holistic interrelations of interactive symptom/diagnosis/ treatment because the issues are interdependent and cannot be diagnosed separately. Many patients present with similar symptoms, but the possible causes may be very different. After using NANDA ND, my clinical brain could not function properly. Sometimes it is impossible to find appropriate ND to describe the situation. Information becomes fragmented. Treatment involves only stop-gap measures for isolated aspects of the problem rather than attempts to find the root cause. Like a rat chasing its tail, the problems found are usually not the real issue. (Oncology nurse with 3 years of experience) Another participant mentioned: We investigated the health problems of 48 patients staying in the hospital. Patient charts revealed a total of 98 ND. None had any issues relevant to psychosocial or spiritual wellbeing. Two patients with different diagnoses were cared for by one nurse and shared the same ND, with even the same notes recorded in their patient files. Since a patients individual situation could not be determined by the records, this represents a shortfall of ND. (Head nurse with 13 years of clinical experience) This interviewee pointed out that the relatively small number of ND categories results in assigning the same nursing diagnoses to patients with very different conditions. Moreover, a patients individual condition cannot be deduced from NANDA ND records. Seven of the 53 participants had studied NANDA ND during their formal education but did not use them in their clinical setting, being employed in workplaces where NANDA ND were not employed. One of these seven mentioned that

Results
The dominant finding herein was a struggle to reconcile a Chinese-based holistic view of nursing care with the digital check-box NANDA ND viewpoint. The preliminary theoretical framework is summarized by the phrase, Struggling with (the NANDA ND notion that) One Size Fits All, expressed hereafter as Struggling with One Size Fits All. Five main categories and 16 subcategories illustrate the combined impressions of the interviewees (Figure 1). Each main category is represented by an initial of NANDA: N = Nursing journey from novice to expert is compromised; A = Absence of critical thinking; N = Nursing care becomes rigid; D = Detracts from the essence of good nursing; A = A pill for every ill. The core concept, main categories, and subcategories are elaborated in the following.

The Core Concept Struggling With One Size Fits All

The core concept, Struggling with One Size Fits All, emerged after dynamic critical analysis of NANDA NDs impact on patient care and nursing professional development. It refers

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Lai et al. by her educations end, she had developed a negative attitude toward NANDA ND and thus avoided clinical settings where NANDA ND were employed, saying: ND are just like using a set formula. . . . The emotional contact that is so strongly identified with good nursing is lost. I choose workplaces where NANDA ND are not employed. (Nurse with 2 years of experience) (coded as Thinking linearly). Nurses become too lazy to explore the possibility of other issues (coded as Comprehension by analogy). (Nurse with 9 years of clinical experience) ND make for quick diagnosis, but the nurse becomes a mindless peripheral device controlled by a simple digital menu. ND are like forced answers. After you memorize it, you fill it in every time you see a blank space on a page (coded as Reflex), writing without thinking (coded as Reflection). (Nurse with 26 years of experience)

47

Main Categories
The core concept Struggling with One Size Fits All consisted of five main categories and 16 subcategories. Subcategory descriptions with representative interviewee responses are included for clarity. The main categories are discussed next. fessional growth via two subcategories: Good for novices, easy to follow. Participants felt NANDA ND are suitable for guiding nonexpert personnel in standard relatively mechanical situations. NANDA ND provide novices with guidelines containing defining characteristics and related factors to fit patient conditions that can be easily related to a patients basic nursing care issue. (Nurse with 6 years of experience) Bad for experts, limits professional growth. Although 31 participants (58%) had supervised the practice or practical training of NANDA ND for new nursing staff or students, participants believed prolonged use limits nursing professional development. For example, one interviewee mentioned: Prolonged use of stable uniform ND makes nurses consider only a rigid and limited list of options and disregard unlisted factor. . . . Professional growth is nowhere to be seen . . . decades without change. (Nurse with 26 years of experience)

N = Nursing Care Becomes Rigid. Day-to-day fitting of

N = Nursing Journey From Novice to Expert Is Compromised. Interviewees agreed NANDA ND affected pro-

NANDA ND was an ongoing struggle that contributed to nursing care becoming rigid and stereotyped via four subcategories: (a) Structural science versus Creative art, (b) Reductionist approach versus Factorally rich approach, (c) Labeling approach versus Humanized approach, (d) Nursing for recording versus Recording for nursing. These were opposing concepts, the latter in all four sets representing good nursing. It was felt that NANDA ND software offers real convenience but is not optimal for patient care and leads to loss of the art, beauty, and creativity of nursing care. With the variety of individualized conditions in clinical work, this leads to dehumanized oversimplified care. Attention is on the ND list and not on the patient, whereby the principles of good nursing are lost. For example: Stable uniform ND strongly encourage fixed handling of nursing care, without innovation or creativity (coded as Structural science vs. Creative art). The nurse becomes an inflexible robot. . . . The simple preset ND options cannot cover the complexity of patient issue (coded as Reductionist approach vs. Factorally-rich approach). (Nurse with 5 years of hospice experience) ND tend to mark patients with labels, e.g., noncompliance, knowledge deficit, etc. Forcing ND on a patients problems hurts a patients dignity. Only the relationship between the label and the patient exists (coded as Labeling approach vs. Humanized approach) (Supervisor with 20 years of experience) Nurses quickly finish recording and call it a day. The care relationship becomes dominated by the need to click and then obey the clicked ND rule (Coded as Nursing for recording vs. Recording for nursing) (Head nurse with 11 years of experience)

A = Absence of Critical Thinking. All felt that NANDA ND software is convenient, but questions about prolonged NANDA ND use generated two subcategories: (a) Thinking linearly versus Comprehension by analogy and (b) Reflex versus Reflection. These were opposing concepts, the latter representing good nursing as defined by TNAC. Participants felt NANDA NDs unmodifiable one-click choices limit thinking, thereby tending to suppress clinical problem solving abilities.
If nurses consider only the ND list of options, that reduces critical thinking. Superficially similar situations may be treated in the same way and awareness of differences is suppressed. Thinking becomes rigid

NANDA NDs one-size-fits-all approach detracted from good nursing via four subcategories: (a) Same careNo Individuality; (b) Deals with pieces of the patientNo

D = Detracts From the Essence of Good Nursing.

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48 Integration; (c) Everyone plays soloNo Continuity; (d) Do it by the bookNo Meaningfulness. Same careNo Individuality. Participants felt nursing must encompass a holistic mutually aware view of individual patients and that NANDA ND lead to overgeneralization of patients situations. Patients may receive inappropriately identical nursing care because of similar superficial symptoms. ND fall easily into narrow treatment stereotypes. With ND, nursing care is like ordering a meal from a fast food menu. (Head nurse with 11 years of experience) Deals with pieces of the patientNo Integration. Participants noted that each human is a complex system. What happens to a small component may affect the entire system. NANDA ND neglect interactive overlapping problems of a person. One participant noted: ND separate disease and person. ND treat individual pieces of a patient and ignore the whole of a person. (Supervisor with 37 years of experience) Everyone plays soloNo Continuity. ND recording fails to achieve the goal of facilitating communication or tracking patient issues. One participant stated: ND use predefined content and cannot make timely changes. Team members rarely see each others recordings. (Nurse with 4 years of experience) Do it by the bookNo Meaningfulness. ND detract from the sense of accomplishment and meaningfulness obtained through the process of diagnosis. For example, one participant said: Data are recorded because it is a required routine. The focus should be on the patient as opposed to recordkeeping for no good reason. ND encourage that everyone receives the same care, although each patient is essentially a new challenge. (Nurse with 9 years of experience)

Journal of T ranscultural Nursing 24(1) clinical situations have no corresponding ND category. When there is no ND for a patients situation, no entry is made or a random entry is selected. (Nurse with 6 years of experience) Tailoring patients to fit diagnoses versus Tailoring diagnoses to fit patients. Participants felt that uniform NANDA ND hindered accurate diagnosis of the real issue. One interviewee mentioned: ND are rigidly applied like a formula. Even if an ND term does not fit a patient very well, the closest term on the menu is used. For example, patients said lack of Qi (Qi in TCM can be described as an imbalance of life-force); the closest ND term of activity intolerance does not reflect this condition. Individual issues versus Generalized terms. ND are not well suited to record individual cases. Instead, ND generalize. It is inappropriate to use ramrod words on patients. If a patient has diaper rash, the only related ND available is skin integrity, impaired instead of the real problem. (Nurse with 9 years of experience) Common language versus Communication gap. NANDA ND terminology is quite different than medical language. Doctors tend to lack knowledge of NANDA terms. This creates health care team communication gaps. ND uses many terms not found elsewhere in the world of health care. For example, physicians have no immediate understanding of risk for impaired skin integrity or ineffective breathing pattern. Therefore, professionals of different specialties rarely see nursing records. (Nurse with 4 years of experience)

Discussion
The predominant finding of our interviews was that Taiwanese nursing professionals, although quite competent with NANDA ND, felt that a more holistic, balanced view of patients in nursing care was needed. The holistic, circular, interactively dynamic yin/yang of historical Chinese culture unconsciously conditions Taiwanese nurses to expect a logical tree with interactive and customizable potential suited to holistic symptom/diagnosis/treatment. This supports the premise that the complexity of human behavior, including nursing behavior, is strongly culturally bound (Leininger, 1992). Most modern cultures use modern scientific medicine. However, Chinese culture and TCM have philosophical underpinnings, which can significantly alter the perception of nursing care. The beliefs of the eight hexigrams (Bagua) and the yin/yang balance permeate TCM, unconsciously biasing Taiwanese/Chinese nurses trained in Western medical science. Thus, Taiwanese nursing care emphasizes ideas

A = A Pill for Every Ill. NANDA ND represents an attempt

at a standardized international language for nursing care, which may be able function internationally to the satisfaction of all. But one nurse with 10 years of experience in this study described ND as a pill for every ill. Moreover, our participants felt that the present NANDA ND fails to customize care for individual patients via four subcategories. Vague definitionsConfuses issues. Participants noted that a limited inflexible language does not fit the real issues of good health care. One nurse said: ND definitions are often hard to use and understand, particularly with psychological issues. Many complex

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Lai et al. such as implied by the idiomatic expression qian yi fa dong quan shen (Pull one hair and you move the whole body), that is, what happens to a small component may affect the entire system. In contrast, NANDA ND break large problems into isolated logical blocks from which linear hierarchical logical structures are built, with no cross-linking of the logical blocks. NANDA ND are designed for easy implementation in digital systems, unconsciously limiting the organizational possibilities of the diagnostic categories. Taiwanese nurses desire for holistic care and their relative discomfort with NANDA ND seem strongly influenced by traditional Chinese logical attitudes, which struggle against their modern medical training. The findings suggest that NANDA ND needs more options than the available check list, especially the recognition of part/whole interactive physical/psychological/social/ spiritual effects and interpersonal relationships. Chinese nursing care emphasizes treating patients as relatives rather than forcing diagnostic labels on patients. In contrast, the modern West emphasizes technical nursing care tasks and outcomes (Attree, 2001). The findings regarding personal involvement seem significantly in tune with the notions of good nursing in other East Asian cultures, for example, Japan (Izumi, Konishi, Yahiro, & Kodama., 2006). The findings indicate that cultural values effect the perceptions of health care professionals embedded in different cultures. Hogston (1997) studied NDs failure to gain momentum among U.K. nurses, speculating that successful multicultural ND must account for significant elements of the local culture. NANDA ND are intended to become a common nursing language (Gordon, 1998; Hogston, 1997), but this study indicated that NANDA ND fail to convey a recognizable image of a patients real needs. This was one of the strongest impressions of our interviewees and is consistent with Andersen and Briggs (1988), who pointed out that 44% of ND did not reflect real nursing care situations. Carpenito (1984) questioned whether ND adequately reflected nursing care activities. Furthermore, cross-disciplinary health care professionals are often unfamiliar with ND, thus adversely affecting team member communication and health care follow-up. However, other studies reported ND standardized nursing language, improved nursing care, facilitated crossteam communication, and avoided vague nursing terminology (Figoski & Downey, 2006; Gordon, 1998; Hogston, 1997). One explanation for this contrast could be that ND may be perceived differently among different groups and cultures. Using ND risks nursing becoming a series of technical administrative tasks. The interviewees expressed a strong desire for ND to provide (a) greater nurse/patient personal involvement, (b) enhanced communication between health care professionals, (c) holistic consideration of patient symptoms and their nuances, (d) holistic awareness of a unique patient in a unique context. Nursing care plans should be customized according to a patients needs, as reflected in the

49 elements of good nursing (Izumi et al., 2006; Kitson, 1999). The question of how best to collect and apply such data, especially in a multicultural context, is an ongoing challenge. Thus, if NANDA ND are to become a truly international nursing language, these must be sensitive to subtle differences in health care between cultures.

Limitations of This Study

This qualitative study considered NANDA ND from the viewpoints of Taiwan nursing professionals. It was culturally specific to contemporary Taiwan and needs to be reassessed for different cultural contexts. The present study can be treated as preliminary research because there were no quantitative measures of nursing efficacy or comparison of patient outcomes with/without NANDA ND. Only the subjective opinions of a small set of nursing professionals were considered. Consistent with GT methodology, readers are the final authority on the transferability of the theory generated, based on their own meanings and contexts (Chiovitti & Piran, 2003). No grand theory is presented. Such would require studying NANDA ND in different clinical practice areas with nurses from various cultural contexts.

Implications for Research and Practice

The differential effects of use/nonuse and training/nontraining of NANDA ND on East Asian novice nurses relative to senior nurses are fertile areas for research. Further research regarding language, data formatting, and record keeping effects on nursing is needed. This studys results can be used as a reference in clinical nursing care, transcultural nursing, education, research, policy making, the design of higher levels of software for health care data logging, and the design of an improved international and interdisciplinary nursing language.

Conclusion
This study investigated NANDA NDs applicability from the perspective of Taiwan nursing professionals. The use of NANDA ND was generally not favored because of negative effects on the growth and quality of professional clinical nursing. The primary problem seemed to be conflicting cultural Chinese/Western health care values. Similar problems may emerge in other non-American cultures. This studys preliminary theoretical framework suggests that cultural parameters be considered when implementing technologies across cultures. It is hoped that this framework will offer useful insights to help induce a continued dialogue among nursing professionals and catalyze positive change. Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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50 Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Science Council, Taipei, Taiwan.

Journal of T ranscultural Nursing 24(1)

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