Seeing Beyond the Stigma: Social Inclusion and Exclusion in Nursing Care

In every nurse’s career, there are people whose stories challenge us to look beyond the surface, to see the complex intersections of health, identity, and circumstance. Consider Alex and Sharna, a couple who have navigated many years of living in relationship with opioids, including stretches of reduced use and times when they were not using at all. Their histories hold layers of trauma, loss, resilience, and care, as well as repeated efforts to adapt, survive, and move toward safety and stability. Yet, for many clinicians, the ways their lives show up in care, the missed appointments, periods of renewed use, or struggles with mental health, can still trigger frustration before compassion.   

Stigma is not just an attitude; it is a social process that shapes care. Link and Phelan (2001) describe stigma as a relationship between labeling, stereotyping, separation, status loss, and discrimination, all operating within unequal power dynamics. In the healthcare setting, these processes can quietly embed themselves in everyday routines: a raised eyebrow at a late arrival, a tone of disbelief when discussing housing instability, or an assumption that relapse equals failure instead of an expected part of recovery. 

The Fabric of Exclusion in Clinical Spaces 

Social exclusion is not always easy to see; it might subtly show up in policies and procedures that appear neutral on the surface. For example, methadone maintenance treatment (MMT) programs operate within strict attendance protocols, requiring clients to appear daily because of risk of dose interruption. While policy consistency ensures accountability and safety, it can also exclude people who face unstable housing, transportation barriers, or mental illness. When a client misses doses, the narrative often becomes one of “noncompliance” rather than structural vulnerability. 

Nurses are positioned at the intersection between the institution’s rules and the client’s lived reality. How we interpret behavior determines whether care becomes inclusive or exclusionary. Asking “What barriers could be influencing this pattern?” reframes the issue from moral judgment to systemic understanding. 

Seeing the Whole Person 

Alex’s mother, for instance, modeled harm reduction to her family and community long before it became a public health strategy. They taught her child to use sterile needles even while living with addiction. From a social justice lens, this act expresses dignity and maternal care despite deeply stigmatized circumstances. Nurses can embrace this same spirit by recognizing strengths within marginalized narratives. Nurses can and should view survival strategies as evidence of resourcefulness rather than dysfunction. 

Language, Documentation, and Design 

Inclusion in healthcare begins with language, and that includes the words baked into our electronic forms, drop‑down menus, and templates. Thoughtful design of electronic health records can either reproduce stigma or actively interrupt it by making respectful, person‑centred documentation the default rather than the exception. 

Instead of offering “non‑compliant” or “drug seeker” as ready‑made phrases, 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.” Similarly, person-first language should be used to centre the human being in front of us rather than focusing on an illness or diagnosis. When EHR templates prompt nurses to describe context (housing, transportation, trauma, access to services) alongside clinical data, they support a fuller story of the person’s life rather than reducing them to risk labels. 

Design choices like removing stigmatizing shortcuts, embedding inclusive language in standard phrases, and adding decision‑support prompts about social determinants of health all help shift documentation culture. In this way, reflecting on tone and documentation is not only an individual practice issue but also a design issue: well‑designed health records can quietly nudge everyday clinical documentation toward dignity, compassion, and social inclusion, while also allowing for better use of this data for unit‑, organizational‑, and population‑level decision‑making. 

Building Inclusive Nursing Practice 

Link and Phelan remind us that dismantling stigma requires structural as well as interpersonal change. At the bedside, inclusion means meeting people where they are, co‑creating care goals, and explicitly acknowledging the social and structural conditions shaping their health. In documentation, it means using person‑first, strengths‑based language and recording context (not just subjective description or interpretation of behaviours) so that charts reflect people’s realities rather than stereotypes. 
 

At the organizational level, inclusion requires system‑wide flexibility: harm reduction–oriented policies, accessible scheduling, and staff education on trauma‑ and violence‑informed care. 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 default rather than an individual exception. To “see beyond the stigma” is to understand that health inequity is not an individual failing but a reflection of social structures. When nurses centre inclusion in both relationships and systems, we not only deliver care: we enact justice.