Seeing Beyond Stigma — Inclusion, Documentation, and the Ethics of Care

In this third article of Seeing Beyond the Stigma: Nursing Practice at the Margins, the story no longer begins with “What is stigma?” or “Who are Alex and Sharna?” We have already explored those questions (if you haven’t, go read articles 1 and 2 of this series). Their missed doses, late arrivals, and visible distress are now understood as part of lives shaped by poverty, trauma, and structural inequity, not as simple “noncompliance.” The work at this stage is different: it is about what nurses do with that knowledge in the flow of everyday practice, especially in the moments when documentation, policy, and split‑second judgments either deepen exclusion or open the door to more just and inclusive care. 

From Recognition to Responsibility 

In the earlier posts, stigma was named as more than a personal attitude: it was framed as a social process in which people are labelled, stereotyped, separated, and pushed into lower status in ways reinforced by power. Link and Phelan’s description of stigma (recall that this refers to labeling, negative stereotyping, separation into “us” and “them,” status loss, and discrimination...again, if you didn’t read Article 1 and 2 please go take a peak now) helped show how these dynamics are woven through policies, charts, and everyday clinical interactions.  

Once that lens is in place, something shifts. It becomes harder to treat a chart label like “non‑compliant” as a neutral descriptor, or a rigid attendance rule as a purely technical requirement. Knowing that stigma operates through structures and routines turns recognition into responsibility. The core question changes from “Is stigma present in my setting?” to “How am I participating in it and how might I choose differently?” 

How Interpretation Becomes Practice 

Clinical environments demand rapid sense‑making. Nurses constantly interpret: Is this person safe? Are they engaging? What should happen next? These interpretations draw on knowledge and experience, but they also reflect deeply ingrained stories about who is “reliable,” who is “risky,” and who is “worth the extra time.” 

When someone like Alex or Sharna arrives late yet again, several narratives might run through our minds. One might read their lateness as a lack of motivation or respect. Another narrative might gravitate to the fragility of their circumstances: unstable housing, unpredictable transportation, impacts of trauma, or withdrawal affecting sleep and energy. Both narratives can coexist in the same mind; the one that becomes dominant shapes tone, body language, and decisions. 

Over time, these small interpretive moves accumulate. They influence who receives flexibility or creative problem‑solving and who is offered only warnings and consequences. They guide who we believe is distressed and who we automatically doubt. Those reactions, those unconscious biases, are what we need to uncomfortably reflect on, because these narratives and these thought processes that we make inform which stories are written into the chart and which are left unspoken. Seen this way, interpretation is not a private mental process; it is a powerful driver of practice and a key site for anti‑stigma work. 

Documentation as a Site of Change 

Earlier in the series, documentation emerged as one of the main ways stigma becomes durable. Words written in a chart can follow people across units, agencies, and years, shaping how every subsequent clinician approaches them. That reality makes documentation a crucial place to practice differently. 

One shift is from judgment to description. Instead of “non‑compliant with methadone,” a note might read: “Has missed three morning doses this week; describes difficulty with early hours due to unstable housing and lack of reliable transportation; would benefit from exploring more flexible dosing options.” This wording still communicates risk and concern, but it situates behaviour within context and points toward collaboration rather than blame. 

Another shift is deliberate attention to strengths and survival strategies. For someone managing trauma, poverty, and substance use, statements like “returns consistently to care after previous difficult encounters” or “maintains supportive connection with partner and peers” are clinically relevant. Recording these details counters a purely deficit‑based narrative and signals to other providers that there is motivation, persistence, and relational capacity to work with. 

These changes do not require extra time so much as a different orientation: seeing documentation as a place to honour complexity and context rather than collapse people into labels. 

Designing Systems That Support Inclusion 

Individual nurses can do a lot within their own charts, but systems shape what is easy or difficult to sustain over time. If electronic forms are built around stigmatizing shortcuts (pick lists that include terms/concepts like “non‑compliant,” “drug seeker,” or “manipulative”) even reflective clinicians are nudged toward narrow, judgmental language. System design can either reinforce stigma or help interrupt it. 

More inclusive documentation systems might: 

• Remove or de‑prioritize stigmatizing quick‑pick labels that focus on moral judgment rather than describing behaviour and context. 

• Embed person‑first language (for example, “person living with a substance use disorder,” “has experienced barriers to attending appointments”) into common phrases so that respectful wording becomes the default rather than the exception.  

• Prompt clinicians to document social and structural determinants—housing, income, transportation, trauma and violence exposure, racism, colonization—alongside symptoms and risk indicators, supporting a fuller picture of people’s lives.  

• Integrate brief cues or decision‑supports related to harm reduction and trauma‑ and violence‑informed care when documenting substance use or behaviours that are often stigmatized.  

These are design decisions, not just technical tweaks. They signal that understanding context, naming structural barriers, and using non‑stigmatizing language are integral to good clinical practice. Over time, they help align day‑to‑day documentation with the values of equity and social justice that many nurses already hold. 

Moving From Insight to Practice 

If the first article asked readers to notice where stigma lives, and the second invited closer attention to how nurses make sense of people’s stories, this third piece focuses on movement: from insight toward sustained practice and structural change. That movement happens in small, concrete steps. 

It might look like pausing before writing a familiar label and instead choosing words that describe what happened and why. It might look like asking one more question about barriers before concluding that someone “doesn’t care.” It might look like raising concerns about documentation language or rigid attendance rules in a team meeting, even when that feels uncomfortable. 

This is not about achieving perfection or never feeling frustrated. It is about recognizing that frustration and bias are predictable responses in unjust systems—and that part of nursing ethics is noticing when those responses risk becoming practice norms, then choosing to respond differently. 

Questions for Reflection 

To support readers in integrating this work, you could close with questions such as: 

• When I think about people like Alex and Sharna, what automatic stories do I tell myself about why they miss appointments, renew substance use, or arrive distressed? 

• How often do I document the structural and social context of someone’s life as clearly as I document risk, diagnosis, or symptom severity? 

• Can I recall a recent note, handover, or conversation where my language might have reinforced stigma? What might a revised, more descriptive and contextual version sound like? 

• In my current setting, what aspects of our documentation tools or policies make it harder to practice in ways that align with my values of inclusion and justice? 

Ideas to Move Forward 

To translate reflection into action, readers could be invited to try steps like: 

• Choose one stigmatizing term commonly used in your setting and experiment with replacing it with descriptive, person‑first language for the next month, noticing how this shifts your thinking. 

• Intentionally include at least one strength, act of resilience, or example of care in each chart note for people whose lives are heavily shaped by structural inequity. 

• Bring a de‑identified example of problematic documentation language to a team huddle, education session, or supervision meeting and explore alternative wording together. 

• If you are connected to education, quality, or informatics work, advocate for reviewing templates, quick‑pick lists, and standard phrases through an anti‑stigma, harm reduction, and trauma‑ and violence‑informed lens.  

The work of seeing beyond the stigma is not a one‑time realization but an ongoing practice. With each piece of clinical documentation, policy conversation, and design decision, nurses have an opportunity to shift care away from exclusion and closer to justice, especially for those, like Alex and Sharna, whose lives are most entangled with the margins.