How We See Shapes How We Care: Stigma, Documentation, and Everyday Nursing Practice

 In the first article of this series, the focus was on how stigma, social exclusion, and documentation practices can subtly shape the care people receive, especially in settings like methadone clinics. That piece invited us to look at policies, electronic health records, and institutional routines. This second article turns the lens even closer: toward the stories we tell ourselves as nurses when we encounter people whose lives are deeply affected by structural inequity, substance use, and trauma. 

Nurses encounter many people whose lives are shaped by complex intersections of health, identity, trauma, and structural inequity, including those who move in and out of substance use over time. For someone like Alex or Sharna, years of navigating a relationship with opioids can include periods of reduced use, times of not using at all, and ongoing efforts to stay safe, connected, and housed. Despite this resilience, the ways their lives show up in care, for example missed appointments, other providers’ concerns about substance use, or visible and voiced distress and frustration, are still often interpreted through a lens of impatience or blame rather than curiosity and compassion. 

Stigma helps explain why this happens, but not only at the level of individual attitudes. It is a social process in which people are labelled, stereotyped, separated, and pushed into lower status in ways that are reinforced by power and reproduced through everyday practices. When nurses learn and internalize labels like “non‑compliant,” “frequent flyer,” or “drug seeker,” these words do more than sit quietly (and certainly not neutrally) in our minds: they are written into charts, repeated in handovers, embedded in referral letters, and eventually taken up in audits, quality reviews, and policy decisions. 

Once this language is captured in documentation, it can shape care at multiple levels: at the micro level, it influences how individual clinicians speak to and think about a person; at the meso level, it informs unit culture, team expectations, and risk‑management discussions; and at the macro level, it can feed into utilization data, funding decisions, and how “high‑needs” populations are defined. In busy clinical environments, this pattern can surface in tiny moments, like a sigh when someone arrives late to an appointment (again), a doubtful tone when a person describes housing instability, or the assumption that renewed substance use equals failure rather than a common feature of a chronic, relapsing condition. Unless nurses take the lead in consciously recognizing and actively dismantling both our language and our systems, these patterns continue unchecked. And that is a big ask. It requires bold bravery on our part and a radical honesty about the problematic structures we function within. 

Everyday Micro‑Moments of Exclusion 

In the first post, social exclusion showed up in policies and procedures that looked neutral on paper but had unequal impacts in practice. That same pattern plays out in day‑to‑day interactions. Methadone maintenance treatment (MMT) programs, for example, often operate within strict attendance protocols, requiring people to appear daily to prevent dose interruption and promote safety. On paper, this makes sense. In the realities of Alex and Sharna’s lives, these rules intersect with unstable housing, precarious work, limited income, caregiving, trauma, and mental illness. Missing a bus, losing a transit pass, or being immobilized by depression can all mean a missed dose. 

When this happens, the narrative in many clinical spaces quickly becomes one of “noncompliance” rather than structural vulnerability. The focus shifts to individual willpower instead of structural constraint. Nurses are positioned at the intersection between institutional rules and people’s lived realities. How behaviour is interpreted (careless versus overwhelmed, manipulative versus fearful) helps determine whether care becomes inclusive or exclusionary. A simple (but not easy) shift from “Why didn’t they show up?” to “What barriers could be influencing this pattern?” moves the conversation away from moral judgment toward systemic understanding. 

Seeing the Whole Person 

In Article 1, Alex’s and Sharna’s story introduced how stigma can become embedded in documentation and policy. Here, their story pushes us to notice strengths that might be easy to miss. Alex’s mother, for instance, modeled harm reduction to her family and community long before it became a formal public health strategy. She taught her child to use sterile needles even while living with addiction herself. In many dominant narratives, this might only be framed as “parental neglect” or “intergenerational addiction.” From a social justice lens, this act also expresses dignity, love, and a fierce form of care in the midst of deeply stigmatized circumstances. 

Nurses can embrace this same spirit by looking intentionally for strengths within marginalized narratives. Survival strategies like staying connected to a partner, holding onto a peer network, finding ways to self‑medicate unbearable distress, can be recognized as evidence of resourcefulness, courage, and creativity rather than dysfunction. This does not mean romanticizing suffering or ignoring risk; it means holding both risk and resilience at once. When nurses consciously look for evidence of strength, commitment, care, and adaptation, it becomes easier to build partnerships and co‑create meaningful goals, rather than positioning people as passive recipients of correction. 

Language, Documentation, and Design: From Insight to Practice 

The first article highlighted how language in electronic health records and clinical policies can reproduce stigma or interrupt it. Here, the conversation pushes into a more uncomfortable but necessary space: recognizing that how nurses see and make sense of people is reflected not only in our feelings and interactions, but also in the language we choose and the stories we commit to the chart. Inclusion in healthcare begins with language, and that includes the terms embedded in electronic forms, drop‑down menus, and templates. Thoughtful design of electronic health records can either reinforce stigma or actively challenge it by making respectful, person‑centred documentation the default. 

Instead of offering “non‑compliant” or “drug seeker” as ready‑made phrases or quick picks, systems can prioritize neutral, descriptive wording and person‑first options such as “a person living with a substance use disorder” or “has experienced barriers to attending appointments.” Person‑first language centres the human being in front of us rather than focusing solely on an illness, diagnosis, or behaviour. When templates prompt nurses to document context (housing, transportation, trauma, access to services, cultural and community connections) alongside clinical data, they support a fuller story of the person’s life rather than reducing someone to a risk label. 

Design choices like removing stigmatizing shortcuts, embedding inclusive language into standard phrases, and adding decision‑support prompts about social determinants of health can gradually shift documentation culture. Over time, these structural nudges make it easier for nurses to chart in ways that are fair, accurate, and compassionate—even under pressure. Reflecting on tone in documentation then becomes not only an individual practice issue but also a design issue: well‑designed health records can quietly guide everyday clinical documentation toward dignity, compassion, and social inclusion, while also strengthening the quality of data used for unit‑, organizational‑, and population‑level decision‑making. 

Building Inclusive Nursing Practice, One Interpretation at a Time 

Link and Phelan’s work on stigma highlights a central thread in this series: dismantling stigma always requires change at both structural and interpersonal levels. Article 1 focused on policies and documentation systems; this second piece emphasizes that those systems are always filtered through how nurses interpret what they see and hear in practice. 

 
At the bedside, inclusion means meeting people where they are, co‑creating care goals, and explicitly naming the social and structural conditions shaping their health, rather than treating those conditions as background noise. In documentation, it means using person‑first, strengths‑based language and recording context, instead of relying on subjective descriptions or interpretations of behaviours that can harden into labels. More critical analysis (from top to bottom, clinician to researcher to policy maker) is needed to expose how damaging these deeply embedded subjective processes can be, especially when they are taken up as “data” that follows people across services and settings. Policy and practice should therefore strive to ensure that charts reflect people’s realities, not stereotypes, so that records become tools for equity rather than instruments of harm. 

At the organizational level, inclusion continues to require system‑wide flexibility: harm reduction–oriented policies, accessible scheduling, options for lower‑barrier care, and ongoing staff education on trauma‑ and violence‑informed practice. It also includes re‑designing electronic health records so that respectful, non‑stigmatizing language and prompts about social determinants are built into templates and decision supports, making equity‑oriented documentation the norm rather than an individual exception. 

To “see beyond the stigma” is to recognize that health inequity is not an individual failing but a reflection of social structures and histories that shape whose pain is believed and whose suffering is ignored. When nurses centre inclusion in both relationships and systems, we are not only delivering care; we are continuing the work proposed in my previous blog posting. We need to rally and challenge ourselves to dive into a place of discomfort, participating in the everyday practice of justice for patients (who we should be clear, are also us), chart note by chart note, interaction by interaction, policy by policy.