Mary Lee A. RobertspersName, Martin SchiavenatopersName (2017date). “Othering in the nursing context: A concept analysis.” Nursing Opentitle·j.
Object of study — otheringterm·dom as a social process in nurse-patient, nurse-nurse and inter-professional relationships
Research question — what are the elemental properties of otheringterm·dom in nursingterm·key, and how can the process be disrupted
Contribution — a concept analysisterm·key of otheringterm·dom in nursingterm·key: its related concepts, antecedentsterm·mth, attributes and consequences, and a conceptual foundation for inclusionary strategies
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | othering of patients and colleagues by gender, race and ethnicity in nursing — “Generally, othering is gender, ethnically and/or racially based, although this is not exclusively so and can be extended to include other non‐conforming or “problematic” individuals, colleagues and patients.” | |
| claim-type | existence — “Findings from this concept analysis reveal that othering is a seemingly sequential social process with a resolute trajectory aimed at exclusion and marginalization.” | |
| method — evidence | — “The Rodgers’ Evolutionary Method, an approach specifically developed to analyze an evolving concept based on an interdisciplinary inquiry, served as a procedural guide for this concept analysis” | |
| object of study — evidence | — “To address these challenges, this concept analysis aims to define othering by analyzing its elemental properties in: nurse‐patient, nurse‐nurse and inter‐professional relationships” | |
| research question — evidence | — “To address these challenges, this concept analysis aims to define othering by analyzing its elemental properties in: nurse‐patient, nurse‐nurse and inter‐professional relationships, using the Rodgers’ Evolutionary Method for concept analysis (Rodgers & Knafl, 2000 ).” | |
| contribution — evidence | — “Twenty‐eight papers were analyzed whereby definitions, related concepts and othering attributes were identified. Findings support that othering in nursing is a sequential process with a trajectory aimed at marginalization and exclusion, which in turn has a negative impact on patient care and professional relationships. Implications are discussed in terms of deriving practical solutions to disrupt othering. We conclude with a conceptual foundation designed to support inclusionary strategies in nursing.” | |
| mechanism | dominant-subordinate relationship Difference is created with a subordinate 'other', reinforced through exclusion, which furthers the dominant-subordinate relationship in a self-reinforcing cycle that promotes marginalization. — “This dominance is defined and reinforced by creating difference with a subordinate, “the other”. This differentiation is in turn reinforced through exclusion, thereby furthering the dominant‐subordinate relationship in a cyclical or self‐reinforcing manner that promotes marginalization.” | mechanisms[0] |
| sense | othering - in nursing, a sequential process with a trajectory aimed at marginalization and exclusion, harming patient care and professional relationships — “Findings support that othering in nursing is a sequential process with a trajectory aimed at marginalization and exclusion, which in turn has a negative impact on patient care and professional relationships.” | senses[0] |
| sense | othering - recognized in nursing literature as both conscious and unconscious, whereas social theorists describe it as mostly unconscious — “And where social theorists have suggested that the basic operations and interpersonal processes related to othering are a mostly unconscious process (Bourdieu, 1998 ), nursing literature has recognized both conscious and unconscious formulations of othering.” | senses[1] |
| sense | outsider within - Collins' model: marginalized individuals use their assigned role of the excluded other to construct self-identity and an outsider's perspective on the dominant culture; offered here as an alternative to othering — “Herein, Collins ( 1986 ) has developed an explanatory “outsider within” model illustrating how marginalized individuals use their dominantly assigned role of the excluded “objectified other” to construct self‐identity, self‐valuation and a uniquely informed, albeit “outsider's” perspective of the dominant culture (p. 18).” | senses[2] |
| relation | Inclusionary othering —contrasted-with→ marginalization — Inclusionary othering uses the recognition of difference for alliance building, rather than as a mechanism for reinforcing marginalization — “In these terms, Inclusionary othering uses the recognition of difference for alliance building, rather than as a mechanism for reinforcing marginalization and exclusion.” | concept_edges[0] |
| weight | Inclusionary othering —contrasted-with→ marginalization — 0.75 — “In these terms, Inclusionary othering uses the recognition of difference for alliance building, rather than as a mechanism for reinforcing marginalization and exclusion.” | concept_edges[0] |
| relation | exclusion —part-of→ othering — the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concept_edges[1] |
| weight | exclusion —part-of→ othering — 0.75 — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concept_edges[1] |
| relation | difference —part-of→ othering — the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concept_edges[2] |
| weight | difference —part-of→ othering — 0.75 — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concept_edges[2] |
| replication | not-applicable | |
| no type for this | othering → marginalization — marginalization is understood as an outcome of othering — “In following this definition, marginalization can therefore be understood as an outcome of othering.” | unhoused_relations[0] |
| no type for this | racialization → stereotyping — racialization has been considered a subcategory of stereotyping based on race — “Racialization, in turn, has been considered a subcategory of stereotyping based on the concept of race (Tang & Browne, 2008 ).” | unhoused_relations[1] |
| no type for this | stereotyping → othering — stereotyping may be considered a co-process of othering — “In this sense, stereotyping is defined as a formulaic oversimplification of an individual or group identity and may be considered a co‐process of othering that facilitates classification and exclusive social groupings (Browne, 2007 ).” | unhoused_relations[2] |
| no type for this | dominant power → othering — dominant power, with the normal social standard, is an essential antecedent of othering — “Nursing literature has consistently presented two essential antecedents of othering: the normal social standard and dominant power (Canales, 2010 ; Johnson et al., 2004 ; MacCallum, 2002 ; Weeks, 2005 ).” | unhoused_relations[3] |
| limitation | Empirical evidence of othering in nursing practice is neither measured nor addressed. — “Hence, this study is limited in that empirical evidence of othering in nursing practice is neither measured nor addressed.” | limitations[0] |
| limitation | The range of epistemological and ontological consequences for those involved is beyond the study's scope. — “Unfortunately, an accounting for this range of consequences and the implications for the nursing profession are beyond the scope of this study.” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | Othering negatively affects patient care and inter- and intra-professional relationships. — “As a result, othering negatively affects patient care as well as inter‐professional (e.g. nurse‐physician) and intra‐professional (e.g. nurse‐nurse) relationships.” | content_tags.findings[0] |
| finding | The analysis found limited information on theoretical propositions and interventional solutions for othering. — “Indeed, this reduced conceptual space is evidenced by the findings of this analysis, which indicate limited information regarding theoretical propositions and possible interventional solutions for othering.” | content_tags.findings[1] |
| quantity | 28 — — “These searches yielded a group of 308 sources, which ultimately was reduced to 152 unique documents after accounting for the overlap between databases. Search results were further limited by their specificity to the stated population and the objectives indicated for this analysis, which resulted in a definitive group of 28 sources that met the limits of these criteria.” | content_tags.quantities[0] |
| quantity | less than 10% — — “Hence, with men comprising less than 10% of the current nursing workforce and with only 19% of registered nurses being from ethnic minority backgrounds (United States Health Resources Services Administration, 2014 )” | content_tags.quantities[1] |
| definition | othering — “Othering’ is described as a social process whereby a dominant group or person uses negative attributes to define and subordinate others.” | content_tags.definitions[0] |
| definition | Antecedents — “Antecedents are pre‐existing actions or causes that are consistently associated with a concept.” | content_tags.definitions[1] |
| definition | stereotyping — “In this sense, stereotyping is defined as a formulaic oversimplification of an individual or group identity and may be considered a co‐process of othering that facilitates classification and exclusive social groupings (Browne, 2007 ).” | content_tags.definitions[2] |
| key-terms | othering, marginalization, stereotyping, racialization, exclusion, concept analysis, nursing, Inclusionary othering |
| concept | othering — a social process whereby a dominant group or person uses negative attributes to define and subordinate others — “Othering’ is described as a social process whereby a dominant group or person uses negative attributes to define and subordinate others.” | concepts[0] |
| concept | marginalization — a distinct process that enforces the dominant/subordinate social differences created by othering — “In a nursing research concept analysis of marginalization, Vasas ( 2005 ) has suggested that marginalization can be described as a distinct process that enforces the dominant/subordinate social differences created by othering.” | concepts[1] |
| concept | stereotyping — a formulaic oversimplification of an individual or group identity — “In this sense, stereotyping is defined as a formulaic oversimplification of an individual or group identity and may be considered a co‐process of othering that facilitates classification and exclusive social groupings (Browne, 2007 ).” | concepts[2] |
| concept | racialization — a subcategory of stereotyping based on the concept of race — “Racialization, in turn, has been considered a subcategory of stereotyping based on the concept of race (Tang & Browne, 2008 ).” | concepts[3] |
| concept | Inclusionary othering — uses the recognition of difference for alliance building, rather than as a mechanism for reinforcing marginalization and exclusion — “In these terms, Inclusionary othering uses the recognition of difference for alliance building, rather than as a mechanism for reinforcing marginalization and exclusion.” | concepts[4] |
| concept | exclusion — not defined in this paper's own words; “an essential attribute to the othering process” — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concepts[5] |
| concept | difference — not defined in this paper's own words; an attribute of othering — “Nursing literature has consistently listed the following attributes as part of a conceptualization of othering: the dominant‐subordinate relationship, difference, identity and exclusion” | concepts[6] |
| concept | world‐travelling — an extension of oneself by “travelling” to the world of “the other” — “Herein world‐travelling is conceptualized as an extension of oneself by “travelling” to the world of “the other”.” | concepts[7] |
| concept | role‐taking — not defined in this paper's own words; a concept “originating in social theory and feminist literature that” serves as a construct for building inclusionary relationships — “two related concepts originating in social theory and feminist literature that serve as constructs for building inclusionary relationships.” | concepts[8] |
| concept | Antecedents — pre‐existing actions or causes that are consistently associated with a concept — “Antecedents are pre‐existing actions or causes that are consistently associated with a concept.” | concepts[9] |
| concept | exemplar — serves to illustrate how a concept operates in the nursing practice context — “The exemplar serves to illustrate how a concept operates in the nursing practice context (Rodgers & Knafl, 2000 ).” | concepts[10] |
| concept | dominant power — not defined in this paper's own words; with the normal social standard, one of “two essential antecedents of othering” — “Nursing literature has consistently presented two essential antecedents of othering: the normal social standard and dominant power (Canales, 2010 ; Johnson et al., 2004 ; MacCallum, 2002 ; Weeks, 2005 ).” | concepts[11] |
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Otheringterm·dom in the nursingterm·key context: A concept analysisterm·key Abstract ‘Otheringterm·dom’ is described as a social process whereby a dominant group or person uses negative attributes to define and subordinate others. Literature suggests otheringterm·dom creates exclusive relationships and puts patients at risk for suboptimal care. A concept analysisterm·key delineating the properties of otheringterm·dom was conducted to develop knowledge to support inclusionary practices in nursingterm·key.
Rodgers’ Evolutionary Method for concept analysisterm·key guided this study.
The following databases were searched spanning the years 1999–2015: CINAHL , PUBMED , Psych INFO and Google. Search terms included “otheringterm·dom”, “nurse”, “other”, “exclusionterm·dom” and “patient”.
Twenty‐eight papers were analyzed whereby definitions, related concepts and otheringterm·dom attributes were identified. Findings support that otheringterm·dom in nursingterm·key is a sequential process with a trajectory aimed at marginalizationterm·dom and exclusionterm·dom, which in turn has a negative impact on patient care and professional relationships. Implications are discussed in terms of deriving practical solutions to disrupt otheringterm·dom. We conclude with a conceptual foundation designed to support inclusionary strategies in nursingterm·key.
Introduction In her illustrative and appropriately titled work, The Second Sex , Simone de Beauvoir provides a formative analysis of otheringterm·dom by specifying the ways men have consistently exerted their personal power to define women as “The Other” (De Beauvoir, 1989 ). Herein, de Beauvoir explains how men have often initiated a process of‐ otheringterm·dom by differentiating women according to a dominant male standard: “She is defined and differentiated with reference to man and not he with reference to her; she is the incidental, the inessential as opposed to the essential. He is the Subject, he is the Absolute – she is the Other” (De Beauvoir, 1989 , p. xxii). In feminist literature this interpersonal process of generating of “the other”, otherwise identified simply as otheringterm·dom, has been used to describe a sequence of events, whereby a person or group is differentiated from a dominant group in accordance with a chauvinistic social standard (Anzaldua, 1987 ). On the whole, nursingterm·key research has supported this premise, while indicating that differenceterm·dom is a foundational attribute to the otheringterm·dom process (Canales, 2010 ). In a similar way, social theorists have described otheringterm·dom as a process by which interpersonal differentiation generates a distinct form of social exclusionterm·dom and subordination (Bourdieu, 1984 , 1998 ; Dervin, 2012 ).
Background In the early 2000s, nursingterm·key researchers began using these and similar descriptions to work at framing otheringterm·dom as a mostly negative and exclusionary process that can often times be based on racial and/or ethnic biases (Canales, 2000 , 2010 ). For example, it was in these explorations into otheringterm·dom in nursingterm·key practice where the otheringterm·dom concept emerged as a useful descriptor of adverse nurse‐patient encounters, especially in cases where patients were differentiated into racial and ethnic categories and treated in a subordinating way (Browne, 2007 ; Johnson et al., 2004 ). And even though these studies provided ample patient testimony describing the negative and exclusionary environments associated with nurse‐patient otheringterm·dom, no elemental definition aimed at a specific formulation for how otheringterm·dom operates as an inter‐personal social process was proposed, either for nurse‐patient, nurse‐nurse, or inter‐professional relationships.
More recently, research has explored how nurse‐to‐nurse gender‐based differentiation has an impact on the experiences of both male nurses and male nursingterm·key students, particularly in settings where the male nursingterm·key identity is marginalized by a dominantly female‐centric nursingterm·key workforce (MacWilliams, Schmidt, & Bleich, 2013 ). Additional research has worked to align conceptualizations of otheringterm·dom in relation to inequities inherent to inter‐professional relationships, such as the nurse‐physician relationship (Weeks, 2005 ). And although these studies focus on a range of distinct populations, what remains consistent across nursingterm·key literature is the premise that otheringterm·dom can potentially develop into exclusionary patterns of behaviour; the outcome of which is a perpetuation and reinforcement of already existing healthcare, educational and workplace inequities based on gender, race, ethnicity and other categorical social constructs (Ellis, Meeker, & Hyde, 2006 ; Vasas, 2005 ; Weeks, 2005 ).
In exploring options aimed at reducing the impact of exclusionary social processes on patient care, a series of reports emerging from the RobertpersName Wood Johnson Foundation (RWJF) Initiative on the Future of Nursingterm·key suggest that gender diversity and inter‐ethnic inclusion in the nursingterm·key workforce can lead to improvements in patient care (Institute of Medicine, 2011 ; RobertpersName Wood Johnson Foundation, 2012 ). And indeed, several of these RWJF reports indicate that a nurse‐patient inclusionary understanding of gender and ethnic differencesterm·dom promotes better nurse‐patient communication and healthcare outcomes, as some patients are more receptive to healthcare providers from similar backgrounds and gender (Ayoola, 2013 ; Lecher, 2014 ). Hence, with men comprising less than 10% of the current nursingterm·key workforce and with only 19% of registered nurses being from ethnic minority backgrounds (United States Health Resources Services Administration, 2014 ), findings from these RWJF reports suggest that the nursingterm·key profession should confront two direct challenges: (i) Design and implement initiatives aimed at supporting a more gender and racially diverse nursingterm·key workforce; and (ii) Identify and disrupt exclusionary social processes (e.g. otheringterm·dom), which counteract efforts aimed at advancing diversity and inclusion in nursingterm·key practice and across the nursingterm·key workforce (Institute of Medicine, 2011 ; Lecher, 2014 ; RobertpersName Wood Johnson Foundation, 2012 ).
To address these challenges, this concept analysisterm·key aims to define otheringterm·dom by analyzing its elemental properties in: nurse‐patient, nurse‐nurse and inter‐professional relationships, using the Rodgers’ Evolutionary Method for concept analysisterm·key (Rodgers & Knafl, 2000 ). In following a precedence set forth in previous investigations into otheringterm·dom (Canales, 2010 ) and to sharpen our focus on how otheringterm·dom emerges in interpersonal contexts as an operative exclusionary process, this concept analysisterm·key will incorporate writings from feminist and social theorists who have specifically addressed interpersonal exclusionterm·dom and differentiation. The fundamental objectives of this concept analysisterm·key are: (i) Explore the potential for concept‐based findings to inform efforts aimed at disrupting the otheringterm·dom process in nursingterm·key; (ii) Provide information to support gender and ethnic diversity in the nursingterm·key workforce; and (iii) Investigate formulations for inclusionary practices designed to improve patient care.
Methods The Rodgers’ Evolutionary Method, an approach specifically developed to analyze an evolving concept based on an interdisciplinary inquiry, served as a procedural guide for this concept analysisterm·key (Rodgers & Knafl, 2000 ). Our use of this methodological approach was divided into three phases following Tofthagen and Fagerstrom ( 2010 ): (i) The Initial Phase: concept and context are identified and literature is reviewed to obtain data for analysis; (ii) Findings: definitions, related concepts, antecedentsterm·mth, exemplarterm·mth and attributes are identified; and (iii) Discussion: consequences, conclusion and implications for further research. Ethical approval was not required for this study.
The initial phase Concept and context are identified In its most basic conceptualization, otheringterm·dom serves to empower individuals by motivating them to notice comparable differencesterm·dom in others and the particular ways these “others” do not adhere to a dominant social standard (Gillespie, 2007 ). A nurse exerting his/her power to reinforce interpersonal differencesterm·dom based on a dominant social standard—often in terms of race, ethnicity and/or gender—is a recurring example of otheringterm·dom in literature. In this context, nursingterm·key literature has described otheringterm·dom as a process that reinforces a dominant nursingterm·key standard and generates exclusionary, albeit negative relationships amongst healthcare professionals and between patients and nurses (Browne, 2007 ; Canales, 2010 ; Kada, 2010 ).
Literature review and data for analysis The following databases were searched: CINAHL, PUBMED, PsychINFO and Google Scholar. Keyword and title searches for the terms “otheringterm·dom”, “nurse”, “other”, “exclusionterm·dom” and “patient” were carried out for the years 1999–2015. All documents were limited to the English language. These searches yielded a group of 308 sources, which ultimately was reduced to 152 unique documents after accounting for the overlap between databases. Search results were further limited by their specificity to the stated population and the objectives indicated for this analysis, which resulted in a definitive group of 28 sources that met the limits of these criteria.
Findings Definitions Nursingterm·key researchers have regularly used and adopted social theoretical conceptual frameworks to formulate descriptions of otheringterm·dom, where social theorists have explained and described otheringterm·dom and related exclusionary relationships in terms of a sequential process culminating in inter‐relational differentiation and subordination (Bourdieu, 1984 ; Burgess & Park, 1969 ; Said, 1993 ). This process can typically commence with a given dominant person or group recognizing the existence of an accepted “normal” social standard for behaviour, which in turn facilitates the operability of a social environment defined by this dominant person or group. Hence, when this dominant‐defined social environment is challenged and/or stressed by individuals who do not conform to this normal social standard, the dominant person or group responds by identifying and differentiating, that is, otheringterm·dom these non‐conforming individuals, who are then relegated to the status of “the other”. In creating differenceterm·dom through otheringterm·dom, potentially the dominant person or group is empowered while the non‐conforming “others” are consigned to a substandard status, which in theory would restore the dominant‐defined social environment to its former prominent status (Bourdieu, 1998 ; Burgess & Park, 1969 ; Canales, 2000 ).
Nursingterm·key literature has appended to this conceptualization of otheringterm·dom in several fundamental ways. For example, MacCallum ( 2002 ) has accentuated the dual importance of exclusionterm·dom and identity in otheringterm·dom, saying that a group of nurses or patients “is not necessarily defined by those who are in it but by those who are excluded from it”(p. 87). And where social theorists have suggested that the basic operations and interpersonal processes related to otheringterm·dom are a mostly unconscious process (Bourdieu, 1998 ), nursingterm·key literature has recognized both conscious and unconscious formulations of otheringterm·dom. Hence, Canales ( 2000 ) has suggested that otheringterm·dom can at times be manifested as both a conscious and intentional process, while Mee ( 2012 ) and Browne (Browne, 2007 ) suggest that otheringterm·dom is frequently an unconscious, albeit unintentional practice in the nursingterm·key profession.
Related concepts In accordance with its definitional characteristics, otheringterm·dom has principally been associated with exclusionary concepts and social practices. However, with further study and investigation, we find that the otheringterm·dom concept's association with exclusionary social practices has merely served as a point of reference in nursingterm·key; as it is evident that several nursingterm·key researchers have gone on to explore alternative otheringterm·dom‐related concepts and proceeded to reformulate otheringterm·dom into an inclusionary, rather than exclusionary, social process (Canales, 2010 ). For this reason, we present concepts related to otheringterm·dom that are characterized by exclusionary practices, as well as those concepts that appear as inclusionary re‐formulizations of otheringterm·dom and work to construct inclusionary relationships in nursingterm·key practice.
Exclusionary concepts Nursingterm·key literature has consistently associated otheringterm·dom with these related concepts: marginalizationterm·dom, stereotypingterm·dom and racializationterm·dom (Browne, 2007 ; Canales, 2010 ; Evans, 2002 ; Tang & Browne, 2008 ; Vasas, 2005 ). In a nursingterm·key research concept analysisterm·key of marginalizationterm·dom, Vasas ( 2005 ) has suggested that marginalizationterm·dom can be described as a distinct process that enforces the dominant/subordinate social differencesterm·dom created by otheringterm·dom. In following this definition, marginalizationterm·dom can therefore be understood as an outcome of otheringterm·dom. For example, nursingterm·key literature refers to patients subordinated by a dominant bio‐medical otheringterm·dom process as subsequently being marginalized to an excluded status in the healthcare system (Meleis & Im, 1999 ). In a making a similar association with otheringterm·dom, nursingterm·key research has conceptualized stereotypingterm·dom as a tool used by a dominant nursingterm·key group to classify patients or colleagues who do not conform to a normal social standard (Drevdahl, Canales, & Dorcy, 2008 ; Tang & Browne, 2008 ). In this sense, stereotypingterm·dom is defined as a formulaic oversimplification of an individual or group identity and may be considered a co‐process of otheringterm·dom that facilitates classification and exclusive social groupings (Browne, 2007 ). Racializationterm·dom, in turn, has been considered a subcategory of stereotypingterm·dom based on the concept of race (Tang & Browne, 2008 ).
Significantly, numerous sources in nursingterm·key literature have described marginalizationterm·dom, stereotypingterm·dom and racializationterm·dom as predominantly exclusionary processes that are related in some way or form to otheringterm·dom (Browne, 2007 ; Canales, 2010 ; Tang & Browne, 2008 ; Vasas, 2005 ). As will be further elaborated on below, this fundamental and powerful connection between exclusionterm·dom and otheringterm·dom, as exemplified in instances of exclusionary otheringterm·dom in nursingterm·key practice, has had a considerable impact on the quality of patient care.
Inclusionary concepts Inclusionary Otheringterm·dom In contrast to the more ubiquitous exclusionterm·dom‐based characterizations of the otheringterm·dom process, Canales ( 2010 ) has documented multiple situations where marginalized nurses, as well as researchers and scholars, have used the inter‐relational capacities of otheringterm·dom in an antithetical way and reformulated exclusionary otheringterm·dom into an inclusionary social process. In a ten‐year retrospective analysis of otheringterm·dom (spanning 2000–2010), Canales ( 2010 ) presents a survey of the otheringterm·dom concept in nursingterm·key literature, including both exclusionary and inclusionary conceptualizations. Of particular note herein is Canales’ original conceptualization of Inclusionary otheringterm·dom, which is offered as a positive countermeasure to the inherently negative exclusionary form of otheringterm·dom. As was first documented in her research circa 2000, Canales ( 2000 ) has described Inclusionary otheringterm·dom as “a process that strives to connect through differenceterm·dom” (p. 28). In these terms, Inclusionary otheringterm·dom uses the recognition of differenceterm·dom for alliance building, rather than as a mechanism for reinforcing marginalizationterm·dom and exclusionterm·dom.
Role‐takingterm·dom and world‐travellingterm·dom In her early investigations into inclusionary social practices, Canales ( 2000 ) initially situated her formulation for Inclusionary otheringterm·dom in the conceptual context of role‐takingterm·dom and world‐travellingterm·dom; two related concepts originating in social theory and feminist literature that serve as constructs for building inclusionary relationships. Similar to Canales’ ‘inclusionary otheringterm·dom’, nursingterm·key researchers have further defined and subsequently used themes and variations on the role‐takingterm·dom and world‐travellingterm·dom concepts to develop nursingterm·key interventions aimed at countering the negative effects exclusionary otheringterm·dom. For example, Burbank and Martins ( 2010 ) have worked to define a relational mechanism for role‐takingterm·dom, or “taking on the role of the other”, where a recognition for the positive aspects of social differenceterm·dom becomes the means by which coalitions are built based on an interpersonal understanding between nurses, patients and colleagues. In applying the role‐takingterm·dom concept to nursingterm·key education, Phillips and Peterson ( 2005 ) have constructed a comparable formulation for “taking on the role of the other”, which they have used to develop a nursingterm·key education curriculum designed to enhance a nursingterm·key student's awareness for the situational circumstances of marginalized patients.
In a similar conceptualization to role‐takingterm·dom, feminist scholar and writer María Lugones ( 1987 ) has presented world‐travellingterm·dom as way to build relationships based on an understanding of interpersonal differenceterm·dom. Herein world‐travellingterm·dom is conceptualized as an extension of oneself by “travelling” to the world of “the other”. As Lugones ( 1987 ) explains, “Only when we have travelled to each other's ‘worlds’ are we fully subject to each other” (p. 17). Bunkers ( 2003 ) has proposed two nursingterm·key practice‐based manifestations for world‐travellingterm·dom, which are formulated to connect with patients and/or colleagues who may be at risk for, or potentially be socially situated as “the other”. In this context, Bunkers ( 2003 ) sets forth two objectives: (i) Creating a hospitable patient care environment; and (ii) “attending to others with true presence,” as ways to realize world‐travellingterm·dom and “push the edges of the boundaries of lived experiences…[by creating] possibilities for connecting with the stranger [‘the other’]” (pp. 307‐308).
Lastly, it is important to note that these inclusionary processes (inclusionary otheringterm·dom, role‐takingterm·dom, world‐travellingterm·dom) often times arise from and emerge in the negative nature and consequences of the exclusionary form of otheringterm·dom. That is, these inclusionary responses to exclusionary otheringterm·dom may be considered as inherently positive reformulations of the otheringterm·dom process, inasmuch as they work toward manifesting positive outcomes from potentially negative circumstances (Canales, 2010 ).
Antecedentsterm·mth and exemplarterm·mth To develop distinction for an evolving concept, Rodgers’ Evolutionary Method prescribes a delineation of antecedentsterm·mth and an identified exemplarterm·mth. Antecedentsterm·mth are pre‐existing actions or causes that are consistently associated with a concept. The exemplarterm·mth serves to illustrate how a concept operates in the nursingterm·key practice context (Rodgers & Knafl, 2000 ).
Nursingterm·key literature has consistently presented two essential antecedentsterm·mth of otheringterm·dom: the normal social standard and dominant powerterm·dom (Canales, 2010 ; Johnson et al., 2004 ; MacCallum, 2002 ; Weeks, 2005 ). In addition, it is noteworthy that literature has often characterized sources of dominant powerterm·dom, as well as normal social standards in such a way that they appear to instigate and activate the otheringterm·dom process (Canales, 2000 ; Johnson et al., 2004 ). In this sense, the normal social standard and dominant powerterm·dom antecedentsterm·mth co‐operate by working to identify and create differenceterm·dom with non‐conforming individuals, which in turn instigates the otheringterm·dom process and subordinates these individual(s) to a substandard status. The following is an exemplarterm·mth from nursingterm·key literature showing how the normal social standard and dominant powerterm·dom antecedentsterm·mth can become operational in a nursingterm·key care setting and generate multiple instances of otheringterm·dom along with a series of potentially negative outcomes.
The exemplarterm·mth(s) The exemplarterm·mth chosen for this concept analysisterm·key is in fact a compilation of exemplary cases of otheringterm·dom based on Browne's ( 2007 ) ethnographic study: Clinical encounters between nurses and First Nations women in a Western Canadian hospital , which describes the experiences of Canadian nurses and First Nations (Aboriginal or Indigenous) women in a healthcare setting. Herein Browne describes a situation where nurses use a dominant discourse based on assumptive cultural differencesterm·dom to reinforce several normal social standards. In this context, Browne shows how nurses have supported dominant social standards while deriving personal power from reinforcing their assumptions that First Nations patients, in numerous and sometimes subtle ways, do not conform to the socio‐cultural standards set forth by the dominant Canadian cultural power. Before proceeding, it is important to recognize that Browne's findings aim to show how, “nurses (and other providers) are not intentionally [emphasis added] engaging in otheringterm·dom practices” (Browne, 2007 , p. 2724). Still, even in this framework, Browne's findings indicate that the normal social standard and dominant powerterm·dom antecedentsterm·mth remain to be effectual and potentially insidious components of the otheringterm·dom process.
Otheringterm·dom exemplarsterm·mth In multiple observational encounters/sessions where researchers “shadowed” nurses, Browne ( 2007 ) has captured recurring sequences of nurses unintentionally using a socio‐cultural standard, along with their (the nurses’) dominant powerterm·dom status, to initially identify and differentiate First Nations patients and then marginalize these patients to a substandard status. For example, these nurses were quoted as saying: “Some of them [First Nations patients] don't like us at all. You know it's been inbred in them from a very young age. They resent us” (Browne, 2007 , p. 2171). While other nurses were found to assume that First Nations patients could potentially be “unclean or…vectors for infections” (p. 2171). It is noteworthy that many nurses in this study provided commentary explaining how First Nations patients are “different,” (p. 2171) especially in terms of communication styles, but also in seemingly analytical terms, where one nurse is quoted as saying, “What I find is that some patients, the Natives in particular, have a propensity to like narcotics” (p. 2174).
Browne ( 2007 ) also describes how nurses have used their collective power to identify and differentiate the “angry” (p. 2171) First Nations women and strategize ways to reduce contact with these patients. Herein Browne ( 2007 ) comments that nurses were: “Guarding against how the other [First Nations patient] might react [which] contributed to an observable form of social distancing that sometimes occurred between the nurses and some of the First Nations women they cared for” (p. 2171). Hence, by exerting their dominant powerterm·dom to enforce a normal social standard, these nurses effectively situated the First Nations patients into the role of the other, thus providing several exemplary and illustrative cases of otheringterm·dom in nursingterm·key practice.
Browne ( 2007 ) concludes her documentation of this study by noting the clinical outcomes of the otheringterm·dom process: The consequences in terms of clinical practice are not insignificant. Patterns of social distancing, shaped by processes of otheringterm·dom, limit possibilities for therapeutic engagement particularly in relation to patients’ psychosocial, emotion or material needs (p. 2175).
Attributes identified Attribute identification provides a coherent basis for making a concept manifest and distinguishable (Rodgers & Knafl, 2000 ). Nursingterm·key literature has consistently listed the following attributes as part of a conceptualization of otheringterm·dom: the dominant‐subordinate relationship, differenceterm·dom, identity and exclusionterm·dom (Canales, 2000 , 2010 ; Drevdahl et al., 2008 ; Johnson et al., 2004 ; MacCallum, 2002 ). The following describes the tangible ways these attributes operate as definitional qualities of otheringterm·dom and function as conceptual support mechanisms for the otheringterm·dom process in nursingterm·key practice.
Dominant‐subordinate relationship, differenceterm·dom and identity Findings from nursingterm·key literature indicate that the dominant‐subordinate relationship, differenceterm·dom and identity attributes function as interconnected collaborative operators aimed at manifesting an occurrence of otheringterm·dom. Hence, each attribute is formulated in a causal relationship with the other two, collectively working to generate a coherent course or trajectory. In this way, otheringterm·dom is ostensibly identified as a process of differentiation and self‐identity reinforcement, which is sustained and supported by the dominant‐subordinate relationship (Canales, 2000 ; Drevdahl et al., 2008 ; Gillespie, 2007 ; MacCallum, 2002 ).
Nursingterm·key researchers have described the causal relationship between the differentiation and subordination of “the other” as a self‐perpetuating process used by a dominant force to consolidate and increase its identity and power. For example, Weeks ( 2004 , 2005 ) has incorporated this premise into two studies of dominant‐subordinate/physician‐nurse relationships in perioperative and acute care settings. These studies contend that to maintain a powerful identity, the dominant physician entity frequently initiates the otheringterm·dom process to subordinate nurses in practice situations (Weeks, 2004 , 2005 ). In turn, this initiation of the otheringterm·dom process has the potential to generate an impetus for nurses to assert their power as a dominant identity over their subordinates, who may be patients and/or other nursingterm·key colleagues. Feminist theorists postulate that this initial assertion of a dominant powerterm·dom (such as that originating with the dominant physician entity) sets in motion a sequential progression, whereby a series of top‐down/dominant‐to‐subordinate processes of differentiation and subordination occur (Jackson, 1999 ). Canales ( 2000 ) offers a perspective on otheringterm·dom that resonates with this premise, which suggests that the otheringterm·dom process is dependent on the necessary attribute of differentiation and has the potential to reinforce a dominant identity through a series of inter‐dependent dominant‐subordinate relationships.
Exclusionterm·dom The premise for the dominant‐subordinate inter‐dependent relationship has been a recurring and powerful stimulus for feminist and social theorists to further define the paradoxical identity of the socially excluded “other” (Jackson, 1999 ). The essence of this paradox lies in the fact that the otheringterm·dom process, while exemplifying the subordinate identity as visibly different, also excludes subordinate individuals from the dominant social context. In this way, the subordinate identity is made visible by differentiation, while simultaneously being made invisible by exclusionterm·dom (Madrid, 1995 ). It is in these terms that exclusionterm·dom emerges as an essential attribute to the otheringterm·dom process.
In a similar way, nursingterm·key researchers have explored how males, as a gender minority in the female dominated nursingterm·key profession, are at once seen as visibly different, while being excluded from fully participating in and contributing to the advancement of nursingterm·key practice (Evans, 2002 ; O'Lynn & Tranbarger, 2007 ). In a multi‐national literature review, MacWilliams et al. ( 2013 ) present evidence of the ways the dominantly female‐oriented nursingterm·key profession and educational academy have excluded a male‐oriented perspective on nursingterm·key and effectively reduced the male identity in nursingterm·key into a binary categorization of “gay/emasculated” or “he‐man/masculine” stereotypes (MacWilliams et al., 2013 , p. 41).
In nursingterm·key education, male students claim that this binary categorization is partly due to the lack of male nursingterm·key faculty and the scarcity of male professional role models, both of which reinforce the notion that the male presence in the nursingterm·key profession should be viewed as different and therefore non‐standard (O'Lynn, 2004 ). In the midst of this differentiation, male nursingterm·key students have experienced the direct and formative impact of being excluded from the female‐dominated nursingterm·key profession, which has the potential to undermine their (the male nursingterm·key students’) efforts to develop a male‐centric professional identity in preparation for a career in nursingterm·key (McLaughlin, Muldoon, & Moutray, 2010 ; O'Lynn, 2013 ; O'Lynn & Tranbarger, 2007 ). This compelling evidence illustrates how the differenceterm·dom and exclusionterm·dom attributes of otheringterm·dom can work in tandem to have an impact both on individuals and their group identity.
Discussion Consequences It is significant that both parties in the dominant‐subordinate relationship experience a muted capacity for self‐knowledge. For example, a male nursingterm·key student gains quantities of knowledge concerning the dominantly female‐centric nursingterm·key experience, but possibly at the expense of an equal opportunity to develop a personalized male‐centred identity for nursingterm·key practice (O'Lynn & Tranbarger, 2007 ). On the other hand, the dominantly female‐based paradigms perpetuated in nursingterm·key education impede the academy's capacity to evaluate its own curriculum and find ways to learn from and incorporate the male nursingterm·key experience (Grady, Stewardson, & Hall, 2008 ; Kirk, O'Lynn, & Ponton, 2013 ). Similarly, dominant culture and bio‐medical standards often times work in tandem to discourage nurses from researching the ways an inclusionary exchange of nurse‐patient differencesterm·dom can inform practice and improve patient care (Canales, 2000 ).
In providing several contextual analyses regarding the consequences of the dominant‐subordinate relationship in the otheringterm·dom process, Mee ( 2012 ) has proposed that a nurse's limited self‐knowledge of his/her own habitually exclusionary behaviour is often manifested in a practice that unconsciously avoids and isolates those patients characterized as problematic or “aggressive”(p. 17). In consequence, this seemingly unconscious practice of exclusionterm·dom/isolation reduces a patient's capacity to inform nurses of his/her health concerns and significantly puts patients at an increased risk for adverse health outcomes. For example, patients with dementia living in nursingterm·key care centres are over 30% more likely to be admitted to a hospital with avoidable complications such as urinary infections, pressure ulcers and dehydration (Quality Care Commission, 2013 ). Bail et al. ( 2013 ) show evidence that “these complications have been specifically associated with aspects of nursingterm·key work environments”, where limited direct nurse‐patient contact was correlated with a significant increase of a dementia patient's risk for these complications (p. 7).
These examples illustrate not only the barriers by which otheringterm·dom obstructs knowledge development and puts patients at risk, but also the ways this exclusionary social practice reduces the conceptual space to develop alternative processes and solutions. Indeed, this reduced conceptual space is evidenced by the findings of this analysis, which indicate limited information regarding theoretical propositions and possible interventional solutions for otheringterm·dom.
Conclusion and implications for further research Summary of findings Findings from this concept analysisterm·key reveal that otheringterm·dom is a seemingly sequential social process with a resolute trajectory aimed at exclusionterm·dom and marginalizationterm·dom. In addition, evidence suggests that otheringterm·dom occurs as the product of causal and interdependent relationships between key antecedentsterm·mth and attributes that are essential to generating the process. Hence, the otheringterm·dom process begins with an established set of social and psychological conditions that generate a dominant social standard. This dominance is defined and reinforced by creating differenceterm·dom with a subordinate, “the other”. This differentiation is in turn reinforced through exclusionterm·dom, thereby furthering the dominant‐subordinate relationship in a cyclical or self‐reinforcing manner that promotes marginalizationterm·dom. Generally, otheringterm·dom is gender, ethnically and/or racially based, although this is not exclusively so and can be extended to include other non‐conforming or “problematic” individuals, colleagues and patients. Broad evidence confirms that the effects of the otheringterm·dom process are profound and far‐reaching in nursingterm·key practice and across the profession. As a result, otheringterm·dom negatively affects patient care as well as inter‐professional (e.g. nurse‐physician) and intra‐professional (e.g. nurse‐nurse) relationships.
Further research In a summarizing statement regarding the means by which the nursingterm·key profession could possibly evolve to meet the needs of diverse populations Anderson ( 2004 ) has suggested that exclusionary social practices could potentially be obviated by fomenting a culture‐wide “paradigmatic shift” toward inclusionary thinking (p. 14). Even in light of Canales’ ( 2010 ) unique formulations for disengaging social exclusionterm·dom through Inclusionary otheringterm·dom, questions remain regarding the means by which a “paradigmatic shift” toward inclusion, as suggested by Anderson ( 2004 ), is to be effectuated in nursingterm·key practice. Numerous sources have called for broad‐ranging nursingterm·key studies investigating the mechanisms by which dominant social standards are used to formulate fixed gender and racial categories in nursingterm·key, which facilitate otheringterm·dom and related exclusionary processes, such as marginalizationterm·dom (Lynam, Browne, Kirkham, & Anderson, 2007 ; Meleis & Im, 1999 ; Tang & Browne, 2008 ). Indeed, further investigations are needed to establish a knowledge base regarding the operational elements of otheringterm·dom and an accurate articulation of the way “the other” is generated in clinical and educational settings. Future research might also include investigations into the role of the nursingterm·key profession itself and how nursingterm·key practice situations affect the pre‐existing conditions conducive to otheringterm·dom (i.e. the antecedentsterm·mth). In addition, researchers could consider exploring and empirically testing theory‐based interventions aimed at disrupting the attributes or essential contributors to otheringterm·dom, such as differentiation and exclusionterm·dom.
Alternatives to otheringterm·dom Ultimately, the generative purpose of our concept analysisterm·key was to first offer a conceptual basis for understanding how the otheringterm·dom process becomes operable in nursingterm·key and then work to investigate the practical and functional measures the nursingterm·key profession can take to disrupt exclusionary social processes and their negative consequences. For this reason and in consideration for what our analytical findings have revealed, we believe it is worth emphasizing the potential of alternative inclusionary practices that have already been formulated and put into action as countermeasures to the exclusionary outcomes normally associated with otheringterm·dom. Specifically, our analysis has referenced Canales’ ( 2010 ) Inclusionary otheringterm·dom, along with the related concepts of role‐takingterm·dom and world‐travellingterm·dom, as potential guides for thinking about alternative approaches to nursingterm·key practice and collegial engagement based on inclusionary strategies designed to disrupt the potentially exclusionary outcomes of the otheringterm·dom process (Burbank & Martins, 2010 ; Lugones, 1987 ; Phillips & Peterson, 2005 ).
Outsider within In making a broader multi‐disciplinary survey of constructs that work to disable and/or disrupt the otheringterm·dom process, we find that the work of social theorist/African American scholar Patricia Hill Collins ( 1986 ) stands out as exemplary in this regard. Guided by Black feminist literature sources, Collins has formulated a uniquely holistic approach for theorizing the many ways otheringterm·dom may offer a complexity of outcomes. Herein, Collins ( 1986 ) has developed an explanatory “outsider within” model illustrating how marginalized individuals use their dominantly assigned role of the excluded “objectified other” to construct self‐identity, self‐valuation and a uniquely informed, albeit “outsider's” perspective of the dominant culture (p. 18). Armed with a keen sense of self, coupled with a unique perspective on how the dominant culture has subjugated them, these “outsider within”/marginalized individuals, “may reveal aspects of reality obscured by more orthodox approaches” (Collins, 1986 , p. 15).
In granting these uniquely informed marginalized individuals the descriptive title of “outsider within”, Collins ( 1986 ) demonstrates how the distinctive status of an outsider endows and empowers an individual with an informed outside‐to‐inside perspective of the functional social aspects inherent to and “within” the dominant culture. In this way, this specially informed “outsider within” worldview simultaneously explains the status and experience of “the other”, while shedding light on the motives of the dominant force that has relegated “the other” to the margins of society and culture. As described, Collins’ ( 1986 ) unique reformulation of “the other” into the “outsider within” has the potential to inform a broad range of research approaches about the methods by which complex exclusionary social processes can be examined from multiple perspectives and how positive and effective responses could be designed to disrupt the negative effects of exclusionterm·dom.
It is clearly evident that conceptual strategies such as Collins’ ( 1986 ) “outsider within”, along with Canales’ ( 2000 ) “inclusionary otheringterm·dom”, have much to inform the nursingterm·key profession regarding the negative trajectory of the otheringterm·dom process and the possible ways exclusionary practices can be disengaged, while simultaneously empowering inclusionary strategies. As social constructs specifically designed to be antithetical to exclusionterm·dom, the “outsider within” and “inclusionary otheringterm·dom” formulations help guide us toward ways to re‐think and re‐formulate conceptualizations for new approaches to nursingterm·key practice and collegial engagement, which emphasize social processes that support inclusion, while de‐emphasizing and disengaging those processes, such as otheringterm·dom, that generate interpersonal exclusionterm·dom. And indeed, in Canales’ ( 2000 ) and Collins’ ( 1986 ) conceptual frameworks, the trajectory of the otheringterm·dom process is not only disrupted, it is made antithetical to itself and disempowered. Herein, we see the potential for alternatives to the otheringterm·dom process in the form of nursingterm·key interventions, which are designed to empower the “outsider within” characteristics of patients and nursingterm·key colleagues in the interest of creating inclusionary social outcomes.
This work offers a conceptual foundation for considering how otheringterm·dom emerges in the nursingterm·key context. Hence, this study is limited in that empirical evidence of otheringterm·dom in nursingterm·key practice is neither measured nor addressed. In addition, the authors understand that the experience of being engaged in the phenomenon of otheringterm·dom is highly dependent on context and has a range of epistemological and ontological consequences for the individuals and groups involved. Unfortunately, an accounting for this range of consequences and the implications for the nursingterm·key profession are beyond the scope of this study.
In closing we present a brief, yet highly germane excerpt from the writings of literary theorist Edward Said, who over the course of his life and career ardently worked to defend individuals subjected to the process of otheringterm·dom: It is more rewarding —and more difficult—to think concretely and sympathetically, contrapuntally, about others than only about “us”. But this also means not trying to rule others, not trying classify them or put them in hierarchies… (Said, 1993 , p. 336).
Hence, in considering Said's insights and applying them to the nursingterm·key profession, it becomes evident that the necessary task for nursingterm·key is to develop knowledge to support an inclusionary practice, where the many interpersonal differencesterm·dom that emerge amongst diverse individuals are used to strengthen relationships and improve patient care.
Conflicts of interest No conflict of interest has been declared by the authors.