Enduring Controversies. NANDA has been criticized for the multiple levels of abstraction in the diagnostic categories. For example, the category "altered parenting" requires further specification of a taxonomy of "parenting" diagnoses. Fatigue and nausea are diagnoses at a concrete level of abstraction. Two other nagging issues that have followed developers down through the years are associated with the definition of a nursing diagnosis. These issues are the "physiological" diagnoses and "wellness" diagnoses. This controversy surrounding "what is a nursing diagnosis, and what is not," relates to the basic principle of classification: "... successful classification, then, is the ability to ascertain the key or fundamental characteristics on which the classification is to be based" (Bailey, 1994, p.2). Bailey goes on to say that there is no specific formula for identifying key characteristics.

Clinicians' comments regarding "physiological" diagnoses suggest an underlying need for a classification of physiological problems (Kim, 1984). These are treated in collaboration with the physician using both physician-initiated and nurse-initiated interventions. Many of the conditions are not diseases, but rather problems or the potential for complications that require frequent monitoring by the nurse. Decreased cardiac output and impaired gas exchange are examples. Yet, many nurses contend that these collaborative problems (Carpinito, 1995) are not nursing diagnoses, according to the NANDA definition that specifies accountability for the outcome(s).

A second issue concerns the diagnoses relating to "wellness" or health. On one side of the controversy the argument is that prevention involves potential problems or risk states that the nurse is expected, has a duty, and possibly is reimbursed, to treat. Risk states, for example "High Risk for Injury or Falls," describe conditions that require risk reduction through health promotion and preventive intervention. They ask: Why do we need "wellness" diagnoses? The argument continues, if a person does not have a problem, don't diagnose an "effective" state or "potential for enhancement."

On the other side of the controversy nurses argue that there is a need for categories such as "Effective Breastfeeding" and "Potential for Enhanced Community Coping." These guide health promotion and health protection interventions and the identification of strengths (Popkess, 1981). They are particularly important in community nursing, school nursing, and general programs emphasizing health (Lunney, Cavendish, Luise, Richardson, 1997). The counter argument that is given is: Do all persons have "potential for enhanced..." and thus, the diagnosis is a routine? Do some patients not have the potential? Would the term "Desire for Enhanced...," with a defining characteristic that the patient requested help to achieve higher levels of wellness capture the idea?

In regard to the second type of "wellness" diagnosis, Effective Breastfeeding, is this an outcome? Will there be reimbursement for "treatment" if the behavior is already effective? Similarly, will reimbursement be scant for "enhancing potential"? From the theoretical perspectives of some nurses, enhancing potential is the essence of the nurse-patient relationship. The wellness and physiological diagnoses would be excellent topics for a national consensus conference on conceptual (Gordon, 1990) and semantic issues (Nielsen, 1995).

It may be noted that controversies about inclusion and exclusion are not unique to nursing. They involveboth nomenclature and taxonomy issues that are experienced by classifiers in medicine and the sciences. The criticism on the "wellness" side that the NANDA taxonomy is acute care- rather than community-care oriented has to be balanced with the criticism from some nurses on the "physiological" intensive care side that the taxonomy does not sufficiently represent this area of practice. These are some of the issues that make the classification of nursing practice phenomena so intellectually challenging for those involved.