Inequalities in the Everyday of Care: Dimensions of the Incorporation of Intersectional Theory in Nursing Practice

ABSTRACT

Aim

To offer a practical proposal regarding the implications of integrating intersectional theory into nursing practice, drawing from the experiences and narratives of nurses across diverse professional contexts.

Design

Qualitative Grounded theory, following the constructivist approach offered by Kathy Charmaz.

Methods

Data collection was conducted between 2022 and 2023 with nursing professionals from Catalonia, Spain. Following Charmaz's approach, thematic analysis was performed after theoretical sampling was saturated through 17 in‐depth interviews and 2 focus groups.

Results

A total of 26 individuals participated in the study. The analysis identified five dimensions related to considerations for incorporating intersectionality into nursing practice. These dimensions are presented as a conceptual framework, organised from elements most closely related to reflexivity and professional positionality, to those more distally connected to a critique of the structural system within which nursing activities are situated.

Conclusion

Although the findings reveal widespread agreement regarding the necessity of adopting a new perspective that challenges the dominance of biomedical knowledge and facilitates alternative approaches to the social and health complexities in our environments, there exists divergence in the methods for achieving this paradigm shift. Intersectional theory provides a theoretical framework conducive to this reassessment.

Implications for the Profession and/or Patient Care

The findings outlined in this study hold significant implications for both professional practice and the structuring of nursing education at the university level. Concerning professional practice, we advocate for a theoretical framework that offers lucidity and precision regarding the strategies and skill sets necessary for the integration of an intersectional perspective into nursing practice. This framework may prove beneficial not only to individual practitioners but also to managerial entities seeking to reshape institutional care paradigms. In terms of nursing education, this research provides a foundation for a critical revaluation of curricular structures and their practical execution.

Impact (Addressing)

What problem did the study address?

Since health and illness are influenced by social and cultural factors, nursing theories are evolving to address social determinants of health. Strategies are needed to integrate intersectional theory into nursing practice and education.

What were the main findings?

Findings underscore the importance of aligning nursing values with principles of equality, respect, and social justice to address social health inequalities effectively.

Where and on whom will the research have an impact?

This study provides insights into the ambivalence surrounding the incorporation of intersectional theory in nursing practice, shedding light on its perceived value and feasibility among practitioners.

A practical framework is developed which emphasises the significance of understanding power dynamics in healthcare settings and their implications for perpetuating or challenging social inequalities in health.

Reporting Method

The manuscript is based on the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Patient or Public Contribution

No Patient or Public Contribution.

Summary.

• What does this paper contribute to the wider global clinical community?

  • ○
    This study provides insights into the ambivalence surrounding the incorporation of intersectional theory in nursing practice, shedding light on its perceived value and feasibility among practitioners.
  • ○
    Findings underscore the importance of aligning nursing values with principles of equality, respect and social justice to address social health inequalities effectively.
  • ○
    A practical framework is developed which emphasises the significance of understanding power dynamics in healthcare settings and their implications for perpetuating or challenging social inequalities in health.

1. Introduction

Health has become an omnipresent issue in the culture of contemporary societies. (Nettleton 2013). From the socio‐constructivist paradigm, it has been argued that health and illness are not immutable or universal phenomena, but rather the meanings and experiences associated with them are explained through the social and cultural systems and mandates present in individuals and groups (Conrad and Barker 2010). Health disorders become a social construct that can be explained either from its biomedical aspect, referred to as ‘disease’, from the perspective of the subjective experience associated with it, or ‘illness’, and from the socially and collectively attributed meanings, known as ‘sickness’ (Kleinman et al. 1978; Young 1982).

Simultaneously, there is abundant literature supporting the idea that health and illness phenomena cannot be detached from the social conditions in which people live, work, and socialise (Marmot 2005). Poverty, precarity and unequal distribution of goods, resources, access and power are responsible for a social gradient of health both within and between populations (Marmot et al. 2008). Socio‐economic conditions emerge as one of the most relevant determinants of good health, as well as the main cause of existing social inequalities in health in our context (Abbafati et al. 2020).

2. Background

Intersectional theory has provided a conceptual and analytical framework from which to study social inequalities. Stemming from its roots in 1990s black feminism, Kimberlé Crenshaw argued that people's experiences of oppression and inequality could not be understood through singular aspects of their identity, but rather through the confluence of multiple simultaneous identities (Crenshaw 1989). Thus, any approach to the phenomenon of inequality that advocates for a monofocal interpretation (focused on a single axis) or a summative interpretation (the more oppressed positions, the more inequality) is avoided. Instead, an analysis based on understanding the complexity involved in the intersection of multiple axes is advocated (Collins 1993). Applied to the context of health, Hankivsky adds that social inequalities in health are not the result of unique and independent factors, but rather the result of the intersection between different social positions, power relations and experiences (Hankivsky et al. 2014; Hankivsky and Christoffersen 2008). All the above allows us to infer that the experience of illness acts as an intersection between the social construction of illness and the multiple social positions of individuals and groups, generating unique experiences of illness intersected by inequality.

Nursing theories have historically been sensitive to the impact of the environment on health and illness processes (Kérouac et al. 1996). However, in recent decades, multiple voices have emerged advocating for the need to incorporate a more structural perspective in the understanding and nursing approach to health and illness phenomena. Among others, they advocate for examining power relations established in clinical interactions from a critical perspective (Gastaldo and Holmes 1999; Georges 2003); reorienting the professional purpose towards achieving social justice (David 2002); incorporating the social determinants of health model as a theoretical basis for understanding the complexity of health phenomena in person‐centered care models (Lathrop 2020); or revisiting the presence of colonial beliefs and thought in nursing professional practice (Mcgibbon et al. 2014). Additionally, there are various critical voices that have warned of the biases of class, ethnicity and gender that permeate nursing theory and knowledge, and the consequent silencing of ontological and epistemic positions that do not align with Eurocentric norms (De Sousa and Varcoe 2022; Van Herk et al. 2011). Finally, other authors have proposed the incorporation of intersectional theory as an analytical framework in nursing research on health phenomena (Jaynes et al. 2023) or as a reference framework in the planning and design of interventions (Ghasemi et al. 2021; Ruiz et al. 2021).

While there is significant support advocating for the integration of an intersectional perspective into nursing practice, critiques persist, often characterising it as a predominantly theoretical approach with limited practical feasibility. In this regard, the literature includes numerous attempts to propose explanatory frameworks that facilitate its implementation. This study seeks to contribute to these efforts by offering an explanatory model grounded in the experiences of nursing professionals and derived directly from their daily practice.

3. The Study

3.1. Aim

The aim of this study is to analyse the narratives of nurses working in diverse professional contexts regarding their experience of integration of a comprehensive perspective on social health inequalities, ultimately offering a practical proposal for incorporating intersectional theory into nursing practice.

4. Methods

4.1. Design/Theorical Framework

This study is framed within the qualitative paradigm and draws on the theoretical contributions of social constructivism for its epistemic approach. The chosen methodology corresponds to grounded theory, following the constructivist approach offered by Kathy Charmaz (2008). The author proposes an alternative definition to the original vision of Glaser and Strauss (Glaser and Strauss 1967), assuming the undeniable existence of a certain starting position of the research team and emphasising the importance of recognising and clarifying this positioning (Charmaz 2008).

4.2. Study Setting and Recruitment

The participants were selected through theoretical sampling, following the principles of grounded theory (Charmaz 2006b). For this purpose, the main professional areas that constitute the nursing profession were identified: clinical practice, academia (including both teaching and research roles), community agent and policy. Participants were selected from among these areas.

The theoretical sampling process was conducted in three consecutive phases. The first phase involved convenience sampling, identifying professionals who, due to their career trajectory or work position, had been recognised for their contributions to addressing social health inequalities comprehensively. A total of nine individuals were included in this initial sample. Initial contact was made via email, and those who responded affirmatively were informed about the research objectives and invited to provide informed consent for an interview. Of these nine individuals, eight agreed to participate, while one did not respond.

Following this initial phase, a preliminary analysis of the data were conducted, which helped identify emerging themes, saturated narratives and gaps in perspective. This informed the second phase of theoretical sampling, which combined a snowball strategy—where additional participants were identified by the initial respondents—and convenience sampling, targeting individuals deliberately selected to provide counterpoints to the initial narratives. An additional nine participants were recruited during this phase. As with the first phase, this was followed by a preliminary analysis of the data.

The third phase emerged from the need to critically examine and challenge the perspectives identified thus far. This phase involved conducting two thematic focus groups—one with clinical professionals and the other with teacher‐researchers. The focus group guides incorporated elements derived from the preliminary analyses, fostering debate and reflection on the emerging themes. In total, 26 participants comprised the final sample (Table 1).

TABLE 1.

Sample characteristics.

Pseudonym	Gender	Age	Professional area a	Max. academic degree	Qualitative approach
Flora	Woman	40–49	Academic	PhD	Interview
Telma	Woman	50–59	Academic	PhD	Interview
Rosa	Woman	40–49	Academic	PhD	Interview
Diana	Woman	50–59	Academic	PhD	Interview
Rita	Woman	60 or more	Community agent	—	Interview
Lina	Woman	50–59	Community agent	—	Interview
Dara	Woman	50–59	Politics	PhD	Interview
Olivia	Woman	60 or more	Academic	Master's degree	Interview
Elda	Woman	20–29	Clinic	Master's degree	Interview
Jass	Woman	30–39	Clinic	Master's degree	Interview
Sol	Woman	30–39	Community agent	PhD	Interview
Mar	Woman	60 or more	Academic	PhD	Interview
Neka	Woman	40–49	Academic	PhD	Interview
Jan	Man	30–39	Academic	Master's degree	Interview/Focus group
ElPoble	Man	40–49	Academic	PhD	Interview
Beth	Woman	40–49	Politics	PhD	Interview
Eli	Woman	40–49	Clinic	PhD	Interview
Cèlia	Woman	60 or more	Academic	Master's degree	Focus Group
Gina	Woman	40–49	Academic	PhD	Focus Group
Lea	Woman	40–49	Academic	PhD	Focus Group
Iria	Woman	50–59	Academic	PhD	Focus Group
Rut	Woman	50–59	Academic	PhD	Focus Group
Noa	Woman	40–49	Clinic	Master's degree	Focus Group
Aina	Woman	30–39	Clinic	Master's degree	Focus Group
Teo	Man	40–49	Clinic	Bachelor's degree	Focus Group
Lida	Woman	20–29	Clinic	Master's degree	Focus Group

^a Area in which the latest main professional activity was developed in the time of the interview/focus group.

4.3. Inclusion and/or Exclusion Criteria

Inclusion criteria were having a university degree for nursing practice (bachelor's, diploma or equivalent) and having a minimum of 2 years of experience in the field.

4.4. Data Collection

Two data collection strategies were employed: semi‐structured interviews and focus groups. Following the theoretical sampling outlined in previous sections, semi‐structured interviews were used during the first two phases, resulting in a total of 17 completed interviews. Data from the third sampling phase were collected through two focus groups, each designed to foster discussion and reflection on the emerging themes.

Data collection was carried out by the principal investigator, who contacted the participants and conducted all interviews and focus groups. Both techniques were employed with the purpose of approaching the study phenomenon through conversational strategies, which, as Kvale asserts, is a fundamental method of human interaction (Kvale 2011). Regarding the first technique, an interview guide was developed, which was agreed upon by the research team and included key topics for the interview. The interview guide consisted of four main thematic blocks: the first aimed at breaking the ice and understanding the key moments in the participant's trajectory; the second focused on addressing the issue of intersectionality in health and nursing practice; the third explored the professional competencies to be acquired in this integration and the training strategies required to develop them; and finally, the fourth block provided an open space for any remaining issues or topics the interviewee wished to explore further. Additionally, the emergence of unforeseen topics that were relevant to the interviewee was allowed, providing the opportunity to capture the holistic narrative expressed and its grounding in individual experience (Zigon 2012). The interviews were conducted either in person or virtually, depending on the preference of the interviewee, between February 2022 and May 2023. They lasted approximately between 70 and 120 min and were recorded for later verbatim transcription. Additionally, the researcher compiled notes on the development of the conversations that could be of interest for the subsequent analysis.

Regarding the focus groups, the interview guide was revised to include key elements from the previous phases while integrating ideas that emerged during the preliminary analysis of the interviews, aiming to provide greater depth. Two thematic focus groups were organised: one with nurses from academia (6 participants) and another with nurses from clinical practice (4 participants). Both focus groups were conducted in May 2023, lasting between 100 and 120 min.

4.5. Data Analysis

The data collected through semi‐structured interviews and focus groups were transcribed and analysed using the constructivist grounded theory approach described by Charmaz (2006). This analysis followed a two‐phase coding process: initial coding and focused coding.

During the initial coding phase, key segments of meaning emerging from the narratives were identified. This phase involved line‐by‐line coding, allowing the analysis to remain open to multiple theoretical directions without imposing pre‐existing frameworks. As Charmaz states, in this phase, the importance of ‘staying close to the data’ was preserved, enabling the establishment of connections between specific data fragments and conceptual ideas (Charmaz 2006a, 47). Caution was taken, however, as this stage is not considered analysis in itself (Coffey and Atkinson 1996). In the subsequent focused coding phase, the most significant codes were selected and grouped into broader conceptual categories. This phase allowed for the exploration of a higher level of complexity, identifying relationships among codes and creating generalizable categories. As other authors have noted, this process involves grouping codes into meaningful conceptual frameworks (Berenguera et al. 2014; Coffey and Atkinson 1996; Kvale 2011). To further refine the analysis, axial coding, as defined by Corbin and Strauss (1990), was applied. This phase established connections between categories, verifying these relationships against the data and constructing a relational framework of concepts. Axial coding facilitated the identification of causal, resultant and conditional links within the data.

The analysis process was conducted by the principal investigator using Atlas.ti software, version 2022. Themes and categories identified in each phase were cross‐validated with the rest of the research team to ensure further rigour.

4.6. Ethical Considerations

The study received approval from the Ethics Committee of the Fundació de Recerca Sant Joan de Déu on 5 June 2020, obtaining the following code: PIC‐114‐20.

All participants were informed about the study's purposes and the background of the principal investigator prior to their acceptance in the study. This information was provided through a document validated by the aforementioned ethics committee. All participants provided written or verbal informed consent prior to their participation. In verbal cases, consent was given at the beginning of the interview, once the conditions of participation were verified and any questions were addressed and were recorded along with the interview recordings for later custody.

After the interviews and focus groups, literal transcripts of the interviews were returned to the participants for validation. All participants returned the validated interviews, either with minor modifications or with full acceptance of the text. Additionally, participants were asked to choose a pseudonym or allow the research team to assign one. Once assigned, pseudonyms replaced the participants' original identities in all transcripts, with only one file containing the name correspondence, which was kept by the principal investigator. Furthermore, these pseudonyms have been used in all documents derived from the research, including this article.

4.7. Rigour and Reflexivity

The present study integrates reflexivity about the positioning of the research team to achieve methodological coherence (Davis 2012). The research team is composed of professionals from the fields of nursing and social sciences, all with current academic affiliations. The researchers align with the constructivist perspective, which asserts that phenomena are socially constructed and mediated by individual experiences, recognising no privileged source of knowledge above others (Weinberg 2008), but rather advocate for a profound understanding of phenomena through their intersubjective reconstruction (Lincoln and Guba 2005). Furthermore, it should be noted that the research team is influenced by theoretical perspectives from feminism, sociology, and health anthropology, which has allowed for a critical approach to the phenomena under study.

This study adhered to the rigour criteria outlined by Charmaz (2006). Credibility was ensured through the return of interview transcripts to participants for verification, and theoretical saturation was achieved as a criterion for concluding fieldwork. Reflexivity, also in line with Finlay's classification of intersubjective reflexivity (Finlay 2003), was maintained throughout the research, with reflective positions made explicit in the paragraph above. Originality of the study was preserved by ensuring the practical application of intersectional theory within nursing practice and education, an area where literature remains limited. Thus, while the topic itself is not novel, its translation into professional nursing competence is a significant contribution. Resonance, as the ability to explore implicit meanings within the narratives, required a deep analysis of data to uncover both explicit and implicit meanings which led to the unexpected identification of emergent themes, which had not initially been identified as part of the study's focus but essential to full understanding of data. Finally, utility was prioritised from the outset, with findings illustrated through comparisons to similar studies and the development of conceptual frameworks to enhance their applicability to nursing practice and education.

5. Findings

This article aims to address the question of what constitutes a nursing practice that incorporates an intersectional perspective, from the perspective of nursing professionals themselves. To achieve this, the key findings emerged from the narratives have been organised into five dimensions that explain the characteristics of such professional practice, as well as their relationships with each other. Those dimensions aim to provide a conceptual framework that simplifies and operationalise this complex phenomenon.

Dimensions are presented within a consecutive logic by a zoom‐out effect, starting from those aspects closest to professional identity to those that have a more distal impact on the environment. First, it focuses on the elements that delineate the individual position of professionals, then it incorporates aspects related to the perspective and diversity of knowledge that professionals bring. In a third instance, it delves into strategies for approaching the experiences of health and illness of individuals, considering them as essential sources for understanding the confluence and intersection between axes of inequality. In a fourth place, it proposes the general characteristics that should govern nursing actions under intersectional perspective. Finally, the last dimension proposes a critical review of nursing interventions and their limitations, as well as advocating for the need to commit to the values of social justice in health.

5.1. Dimension 1: Introspection

The interviews reveal a shared concern about the importance of critical reflexivity in examining personal experiences that have shaped individual beliefs and values, with the aim of identifying the personal foundations from which professional identity is constructed. This process, referred to as introspection, is grounded in the premise of the non‐neutrality of individuals and, by extension, the inherently subjective nature of nursing practice. Professional identity is conceptualised as a deliberate and conscious process rooted in self‐awareness, wherein individuals critically review their life trajectories to uncover meaningful experiences and identify potential inconsistencies between rational discourse, emotions and actions.

The nurse cannot be neutral, that's already clear. She cannot be neutral because Intersectionality is not neutral. You cannot experience all things in the same way, it's impossible, because the burdens one carries on their back are very different, and that's it. (ElPoble)

This process of introspection, beyond being limited to an individual self‐awareness process, aims to review how individuality translates into professional practice. Some of the interviewees refer to an ‘impregnation of practice’ as a way to describe how they perceive that personal values and positions interfere with professional work. In this professional introspection, understanding both the privilege inherent in one's professional position compared to the population being served, whether due to specialised knowledge or influence in decision‐making, among others, is particularly relevant. But also, the positions of vulnerability involved, whether in terms of one's status within the healthcare professions or due to the feminised nature of the nursing profession. Participants like Lea, a nurse currently engaged in academia, emphasise the importance of ensuring that this reflective process leads to a conscious construction of professional identity.

Becoming a professional is something that must be deliberate; it needs to emerge in your imagination: ‘I want to be this kind of professional,’ and to achieve that, one must work on it. (Lea)

At this point, the interviewees also highlight the possible existence of tensions between personal intersectional positions derived from life experience and professional positions derived from belonging to the nursing collective. Examples of those tensions include participants such as the case of Teo, a male nurse working on clinical setting, who explained how in his private life he has benefited from his male position in a patriarchal framework but perceives vulnerability when identifying as a nurse among other healthcare professionals from traditionally non‐feminised disciplines. Or that of Jass, a woman, nurse and migrant who related how in her private life perceives vulnerability derived from her racialized background but perceives the acquisition of power derived from her specialised knowledge in the society she serves.

Thus, introspection should serve as the initial step in fostering reflection on one's own intersectional positions—namely, the inequalities that shape each professional's life and influence their clinical interactions. This process should allow the professional to step into a safe place that encourages acceptance of others' lives and stories, enabling professionals to approach individuals from a standpoint of equality and respect. Lina, reflecting on her experience as a community worker in one country of South America, emphasises that examining one's own life and the intersectionality within it can reveal shared experiences across different narratives, thereby creating a foundation for mutual understanding.

When we talk about connecting with life, it's also important to connect with our own life because only through self‐awareness can you open to other people. Connecting not only with the external reality but also with my own reality, my life, my story, and relating them to the injustices suffered by other people, also allows us to understand that it's not just individual personal suffering, but behind that there's a global injustice, a political system, an economic system, a gender system, a system of categorizing religions… in short, the intersectional system of powers. (Lina)

As stated in the previous narrative, Lina argues that reviewing one's own intersectional position allows for an approach to the structural causes that underlie the axes of inequality shaping experience, emphasising the global and interconnected nature of domination systems and how they ultimately interfere in the daily lives of communities. Through this connection and contextual understanding, professionals can become aware of the intersectional lens through which they engage and develop an open, non‐judgmental understanding of the position of those they serve.

Finally, several interviewees emphasise that this introspection should also focus on understanding the privilege inherent in the professional position when engaging with individuals and communities. This privilege, they note, arises from asymmetries in access to information and the influence professionals wield over the actions and decision‐making processes of those they serve. Eli, a community nurse working in low‐income urban neighbourhoods, underscores the responsibility that accompanies such privilege and asserts that ‘nurses must not only avoid using this power in ways that exacerbate existing inequalities but also actively channel it towards their mitigation’.

5.2. Dimension 2: Broaden a Structural Perspective

This dimension is based on the statement that ‘what is not named, does not exist’ and is inspired by one of the sub‐competencies of the structural competency model described by Metzl and Hansen (2014) where expanding perspective is equated with broadening the available knowledge framework for each professional; in other words, the reference frameworks they use to explain the observed reality.

Consistent with Metzl and Hansen, the analysed interviews reveal a desire for nurses to broaden their knowledge horizon by incorporating insights from other disciplines and fields. To do so, some interviewees express their critical view of the biomedical model, a theoretical model that they consider obsolete and reductionist in addressing the complexity of current health phenomena. Olivia, a nurse who worked as community agent in low‐income countries and is currently working in academia, defines it as:

Within the current profession, despite the discourse of holistic and integral, the underlying paradigm is still absolutely biomedical. And that means: a body, a dysfunction, a treatment. And this is what somehow limits us from being able to see beyond. (Olivia)

Similarly, participants as Rosa, a nurse with a professional background working on different NGO and currently stablished in academia, identifies as a priority for the nursing community to find in other disciplines and fields knowledge that can problematize the hegemonic biomedical discourse, thus fostering the posing of questions that transcend the clinical reality and also providing alternative answers to what cannot be explained through biomedical discourses.

This biomedical model needs to be rethought. (silence) Because we can't continue with this biomedical model that only focuses on physical illness (…) So, we need to step up ourselves, right? I mean, if we want health for all peoples and global health, we can't just think about the individual's illness and address that illness. (…) I'm not sure there's much room for this model anymore, because I find it hard to see how a biomedical perspective can accommodate such a holistic perspective. (Rosa)

At this point, tensions arise among the analysed narratives, leading to the question: what is considered valid knowledge for nursing? In the analysis conducted, multiple voices emerge advocating not only for an expansion of the range of knowledge from various disciplines and formal sources but also for the incorporation of knowledge from communities and their everyday lives, in other words, from lay knowledge. This entails elevating the experience of health and illness as a sufficient category of knowledge, not just as local perceptions or beliefs (Popay and Williams 1996). Elda, a young nurse with a history of racialization herself, synthetize it with the following words:

I believe being a nurse also means learning from the daily circumstances, learning when you take the metro and encounter something unexpected. I think it's about immersing ourselves in other groups, the group of caregivers, the group of women at home, the group of patients, the group of people with mental disorders… I believe the nursing profession must be open to soaking up other knowledge and other groups. (Elda)

Finally, interviews arise a debate about how the nursing profession itself can (and must) be a generator of new knowledge, thus contributing to the expansion of profesional perspective and the consequent frames of reference. In this sense, there is a clear consensus on the need for the nursing collective to harness its potential in the field of research, providing its holistic view on health and care and stepping forward to occupy a place within academic world.

5.3. Dimension 3: Understanding Inequality Embedded in Everyday Life

This dimension is linked to the previous two as it requires the review and incorporation of both for its application. As expressed by one of the participants, Olivia, a nurse with extensive experience in the community and academic settings, ‘illness cannot be separated from the person and their context; it is part of both’. Thus, the importance is highlighted for nurses to understand how processes of health and illness are embedded in the everyday life of the individuals and communities experiencing them.

For data presentation within this dimension, a widely utilised public health framework was employed to understand the interplay between structural and individual factors: the upstream and downstream approach (Lancet 1994). Regarding de first one, the upstream approach allows professionals to focus on the distal causes that explain health and illness situations in clinical reality. At this point, acquiring a structural mindset (Dimension 2) that enables questioning the root causes of clinical manifestations (Marmot et al. 2008), allows nurses to transcend their scope of practice and focus their actions on addressing these distal causes. In this excerpt, Beth, a public health nurse working in political and governmental settings, emphasises the impact of this perspective on health processes and the optimization of care.

Spain is the second country in the world where more anxiolytics are taken. It is a clear example of the medicalization of everyday miseries. If you, for example can't pay the mortgage on your house because you lost your job, of course you have depression, but that's not cured with anxiolytics, or any pill. We are always looking at the health sector, as the ones to blame for everything, but you know that there is an 80% of issues that shouldn't be addressed only from the health point of view. (Beth)

This narrative exemplifies what another participant, Rosa, referred as the need for the nurses to ‘understand that there are more causes that explains health, all of them beyond the idea of a failing body’.

While this approach enables the identification of the root causes of illness, it has limitations as it requires long‐term structural interventions, which do not address the immediate reality of individuals at risk. Therefore, the downstream approach is equally considered indispensable, described in the interviews as an approach through lived and narrated experience. According to the downstream approach and drawing on the concept of illness introduced by Kleinman et al. (1978), illness can also be understood from the perspective of how it is perceived by those experiencing it and how it impacts their daily lives. It is through the integration of health processes into the subjective reality of daily life, which is intersected by inequality and multiple positionalities, that the nursing profession can address inequality. Diana, a current nurse researcher, draws on her previous professional experience in caring for socially excluded populations to explain that while the upstream approach provides structural awareness, it is the downstream approach that offers the profession a field of action within its professional scope.

The inequalities are indeed in everyday life. Are they upstream? Of course, they are upstream; they are part of the structure! But I believe that we, as nurses, deal with the everyday and, to some extent, these inequalities within the system are also our concern. As a nurse, what you can do is, within your scope, minimize inequalities as much as possible. (…) I believe it is about exploring everyday life, understanding the life of others, the factors that influence their daily lives—ultimately, health is cared for in everyday life, or any health problem is part of everyday life—and understanding that. (Diana)

As Diana's testimony suggests, it is through the expression of everyday life that nurses can address the impact of social inequalities on health. Therefore, understanding the process of illness and its implications for health requires an approach to others' experiences, challenges, and explanatory models, which, in turn, implies a reconsideration of lay knowledge, assuming it as valid knowledge. Jass, a nurse specialised in cultural mediation, emphasises the importance of delving into the explanatory models expressed by individuals and groups as a way to understand the experience of health and illness.

The person in front of you is the master of their reality. This means that the person who knows their reality the best is that individual. Each person has an explanation for why things happen to them, what they associate them with, and how they relate to them. And we ignore it. We often overlook the discourse of individuals. If it doesn't fit with what I've learned or what I'm looking for are numbers or answers to classify them, if the discourse comes out of this category, it no longer exists. (…) If we don't understand all these processes of the person in front of us, we can't approach them. (Jass)

As can be observed, Jass not only emphasises the importance of approaching others' experiences and discursive expressions but also underscores the significance of doing so from a judgement‐free position. In other words, from an open and curious standpoint, willing to listen even to ideas that diverge from one's own, and to understand the underlying beliefs behind people's narratives. Reflecting on what was mentioned in dimension 1 of this study, introspection becomes crucial in fostering this openness. Furthermore, building on the discussion from dimension 2, understanding individuals' explanatory models does not entail a wholesale acceptance of these models as absolute truths. Instead, it serves as a starting point for reflection and critical contextualization from the perspective of various forms of knowledge and understanding.

5.4. Dimension 4: Reframing Nursing Action

This dimension refers to nursing action itself. The analysed interviews display a diversity of opinions regarding how nursing actions should be to address health inequalities. However, despite the present disparity, the following four categories group the main ideas.

On one hand, the importance of adaptability is highlighted, understood as a key skill in healthcare provision. Adaptability is referred as to the professionals' ability to shape their approach and care based on the reality of the person or group being cared for. This adaptation is seen as something that transcends clinical interaction and requires an understanding of the higher structures that shape it. Thus, this capacity avoids any temptation to approach through cultural prescriptions but emphasises the importance of focusing on the intersectional positions that the individuals being cared for incorporate. This adaptability is also identified as a way to recognise the autonomy of individuals to make decisions and avoid exercising power over their bodies and health processes.

We must have a vision towards diversity, meaning, women, within women, black women, young women, women… but differentiate care, which is the difference with the system that measures us all by the same standard, and the protocol should be differentiated because the response of different groups of people is different. It's not the same for a young person as it is for an older person, or a white woman versus a black woman; we have differential physical, emotional, social, geopolitical characteristics, etc. (Lina)

As a second emerging category, nursing action is conceived as connected, meaning an essential but not sole part of a focused health provision mechanism. Thus, nursing work is defined as transitional—in Olivia's words—within a continuum, implying that it precedes and follows other actions simultaneously. Therefore, a nurses add value in their care when they can connect it to the actions of other professionals and devices, thereby bringing resources closer to the individual. In this regard, significant emphasis is placed on ensuring that this connection involves not only formal resources but also that the nurse has extensive knowledge of the informal assets available within the community. Flora, from her care perspective as surgical nurse adds the following:

The nurse should not only be familiar with the individual's context and network but also actively utilize it. Unfortunately, so many times we perceive their network as a problem or a threat to us (Flora).

Thus, the nursing role is identified as one where, faced with a range of resources and devices—both formal and informal—can activate the specific network of those most suitable for the individual and facilitate their access and coordination.

Thirdly, it is emphasised the importance of the nurse being situated, that is, not only knowing the context but also being part of it. Several participants advocated for an involvement based on the bond with the community, and not solely from a technical standpoint. For instance, drawing from a statement by Eli, a community nurse, she emphasises that for her, the nursing role is intrinsically linked to its relevance to the community.

Nurses must have more contact with patients outside the consultation, outside the interaction of our comfortable environment, which is the consultation, the table, etc. We need to go to his house more, participate more in community activities and have a better knowledge of the community and the neighbourhood. (Eli)

Finally, the interviewees emphasise that nursing practice must align with the principles of equality and social justice. They underscore the critical connection between these principles and the first dimension of this model, introspection, advocating for consistency between personal values and professional actions, which necessitates a prior review and recognition of one's values. However, participants like Diana, nurse with a strong social background, acknowledge the challenges inherent in this process, noting the tension between a commitment to value‐driven practice and the constraints imposed by an often capitalist, patriarchal, and biomedical system. Diana describes the system as a ‘phagocytator’ and highlights the ‘cost’ of adhering to these values, which may manifest as additional time, effort or redistribution of power dynamics.

It's very difficult to be in the system and do different things than others do. It's a bigger effort and it means wanting to do it and being willing to pay the cost. You must know how to be inside but also outside and you also have to find people. The system phagocytes, but we have strategies to avoid being phagocytosed. (Diana)

5.5. Dimension 5: Reflexivity and Commitment

As the final dimension, the interviews suggest the need for nursing practice to include an active and critical review of both one's own practice and the system. To illustrate this, we draw on the differentiation proposed by one of the informants in this study, Eli, who poses a distinction between critical positioning aimed at reviewing professional actions, which we label reflexivity, and that directed at advocating for changes in the structural system, which we identify as commitment.

Thus, reflexivity is conceived as the identification of flaws and shortcomings in professional actions. Through reflexivity, nurses are asked to evaluate professional practices, not only in terms of efficiency in health outcomes but also in terms of accessibility, scope, and suitability. However, some interviewees such as Sol, view this cyclical review of actions as costly and tiresome, requiring constant adaptation of actions and the incorporation of a culture of continuous improvement in institutions and professional teams. Sol is a nurse, who has devoted her professional life to developing community public health programs.

The incorporation of this intersectional perspective applied in nursing, I believe, also requires reflection and modification of intervention (…) how they are designed, how they are implemented, how they are evaluated, but also how it has been accepted by population or if it has let someone out. (…). At the end, the intersectional perspective is very rich and very interesting, but it is very tiring and very costly, because it implies asking a lot, it implies a lot of reflection, it implies having to make adaptations. (Sol)

Likewise, this reflexivity implies a review of one's own role and scrutiny of its effects in terms of perpetuating or generating various forms of inequality. Again, this involves reflection on privilege, the power embedded in the professional role, and the position from which professional practice is carried out, elements discussed in dimension 1 of this model.

Regarding commitment, defined by some participants as the need for nurses to also engage in social movements advocating for accessible and quality healthcare rights, echoing Eli's testimony, nurses have ‘a duty to society in advocating for health rights’. Also, other participants as ElPoble states that ‘nursing is political’, considering professional action as a way to perform this commitment. Thus, for them, commitment constitutes a strategy to bring the nurse's voice and their vision of health and care to the public sphere. However, while there is a consensus on the need to enhance this political professional area, voices also highlight its current absence. Dara, a nurse who has developed political functions during the last years of her career, considers that:

The problem is that, in our context, there are many powerful lobbies, and some professions are more dominant than others. Unfortunately, nursing is not a dominant profession in the political domain, and then has little decision‐making power. Therefore, you must fight a lot to get where we can and should be. So, despite having a long way to go, this path is very difficult and not everyone wants to take it. (Dara)

The testimony of Dara is echoed by others, such as Mar, a mental health nurse who has spent recent years working in academia. Mar observes that the nursing profession has been deprived of ‘authority’ within the collective of healthcare professions, limiting its ability to assert a professional voice. She notes that nursing's contributions are often “undervalued”, requiring validation from other professionals to be taken seriously. Similarly, Aina, a clinical nurse at a leading hospital in a major city, emphasises the need for critical self‐reflection within the profession. She states that ‘too often, it is we ourselves who limit the progress of professionals seeking to grow and position themselves in these spaces’.

Thus, while there is a degree of consensus regarding the lack of recognition and public legitimacy afforded to nurses' professional voices as contributing to this political void, attention is also drawn to internal professional dynamics that, at times, hinder some nurses from occupying these spaces.

6. Discussion

This study provides a practical contribution to current literature on nursing approaches to social health inequalities through intersectional theory. The incorporation of intersectional theory in nursing practice elicits an ambivalent stance among interviewees, with some participants supporting its value as a theoretical framework to inform practice and others considering it an unattainable theoretical ideal from the nursing professional reality. This critique is consistent with that mentioned by other authors (Ghasemi et al. 2021), as well as those who have discussed its possible implementation as a framework for professional reflection (Kelly 2011; Ruiz et al. 2021). This article contributes to the existing literature by proposing a conceptual framework for integrating an intersectional perspective into nursing practice, grounded in the lived realities and experiences of nursing professionals. Based on nurses' practice self‐reflection testimonies and through a theoretical dialogue with prior authors and theories, the practical implications of adopting intersectional theory are articulated. These implications have been organised into five distinct dimensions, as visually represented in Figure 1.

FIGURE 1.

Dimensions of the intersectional competence in nursing practice.

Focusing on the first dimension—introspection—it shows some parallelism with other authors statements. For instance, Maykut (2021) suggests a deconstruction of personal identity from intersectional standpoints for the review and conscious construction of professional identity (Maykut 2021). Chinn and Kramer (2015) highlight that self‐knowledge is essential to understand others, and citing Carper (1978), they specify that this self‐awareness must occur in the moment and context in which it occurs. Thus, they discuss a practice based on authenticity when the professional is aware of their own beliefs, attitudes, and values, and is capable to direct their practice in a way that is reconciled with any conflicts it may entail (Chinn and Kramer 2015). This authenticity raises a debate about which values are valid and whether mere alignment between values and actions is sufficient in achieving an intersectional practice aimed at addressing social health inequalities. Through the analysis presented in the framework of this study, the relevance of transcending this reconciliation between beliefs and actions has been argued, emphasising the need for these values to, in turn, be aligned with the principles of equality, respect and social justice.

Simultaneously, the impact of professional power dynamics on clinical practice and interactions with patients has been extensively discussed in the literature. Drawing on Foucault's theories of power and knowledge, the neutrality of science and the truths it produces have been critically examined. Foucault argues that science and its truths establish a hegemonic framework that determines what is considered true or false. Furthermore, he posits that these truths are socially constructed artefacts and, as such, are inherently refutable (Foucault 1980). The privileged status of healthcare professionals is partially sustained by this biomedical truth regime, which places them in an advantaged position relative to the general population by granting them exclusive access to and authority over this knowledge (Gastaldo and Holmes 1999). When combined with individual predispositions and beliefs, this privileged position can contribute to the perpetuation of systemic inequalities (Fitzgerald and Hurst 2017). Acknowledging one's role within this intersection of systemic structures, knowledge sources, and personal beliefs, as suggested by the introspection dimension of the model proposed in this article, is essential for developing a critical professional consciousness.

Such consciousness is pivotal for aligning professional actions with the principles of equity and addressing inequalities in healthcare practice and, as also discussed by participants of this research within dimension 2, highlights the limitations of science centred on a single discipline or theoretical model. As other authors have stated, nursing theory, while historically shaped by interdisciplinary influences, remains deeply rooted in biomedical and positivist discourse. Scholars have critiqued this foundation, advocating for incorporating postcolonial perspectives to challenge power structures in the biomedical model (Horrill et al. 2018) and for posthumanist frameworks which allows to reconsider concepts of identity, autonomy, and personhood in nursing practice (Smith et al. 2022). Furthermore, as other authors have advocated, the acceptance of lay knowledge—narratives and experiences from individuals and communities—as a valid form of knowledge becomes essential to expand understanding of the mechanisms through which health and illness develop and to illustrate its relationship between social circumstances, that is, structure, and individual life (Popay et al. 1998). Therefore, the importance of nursing action being informed by a breadth of sources is emphasised as it offers the opportunity to acquire complementary perspectives to those of the nursing discipline and to contrast them (Metzl and Hansen 2014).

Likewise, the convergence of these multiple forms of knowledge, combined with nurses' critical inquiry, enables them to understand and address the everyday realities in which health and illness phenomena are situated. From an upstream perspective (Lancet 1994), adopting a structural lens allows nurses to transcend their immediate scope of practice and identify actions targeting distal causes of health inequities. Conversely, from a downstream perspective, understanding illness as a representation of social disparities provides a critical field for nursing comprehension of narrative embedded oppressions (Abrams et al. 2020; Chadwick 2017) and intervention in addressing these disparities.

Regarding nursing action, the results obtained from the interviews bear similarities with models that other authors have incorporated. The salutogenic theory, as well as the associated health assets model, align with the idea of nursing as connected and committed to its environment (Antonovsky 1996; Cofiño et al. 2016). From this perspective, the nurse becomes a health promoter who, based on their knowledge of the individual, their environment, and the system, can activate and coordinate resources that best suit the person's needs. Regarding a practice aligned with the values of social justice and self‐critique, others have also highlighted this role, referring to it as health advocacy. This function is defined as aimed at ensuring access, equitable mobilisation of resources, and addressing social inequalities in health through influencing system change and policies (Hubinette et al. 2017). Additionally, some authors have suggested that nurse involvement in the political arena cannot be limited to the individual will of professionals but must be an imperative within the framework of professional responsibility for social justice in health (Boswell et al. 2005).

6.1. Strengths and Limitations of the Work

This study acknowledges potential selection biases in the characteristics and recruitment process of participants. While the qualitative paradigm employed does not aim for generalizable results beyond the study population, certain limitations emerged that should be addressed in future. First, the sampling strategy and inclusion/exclusion criteria excluded perspectives from other professional groups. While this decision aimed to focus on the beliefs and positions of nurses, including voices from other disciplines could have enriched the findings and provided a more interdisciplinary perspective. Furthermore, despite efforts to ensure diversity among participants, a significant proportion of those interviewed were already sensitised to the study's subject matter. Additionally, the sample prominently featured nurses with doctoral grade or those affiliated with academia, reflecting the fact that the themes explored are more actively debated within academic settings. This composition may have overemphasised the consensus among participants and their predisposition towards the study's themes. Second, the study did not include the perspectives of healthcare recipients—the ultimate beneficiaries of nursing care. While their exclusion allowed for a more focused and pragmatic approach, it limited the scope of insights obtained. The complexity of the study topic and the lack of established frameworks necessitated prioritising depth over breadth. Thus, this research serves as a starting point for future studies to incorporate diverse viewpoints and further enrich understanding of the subject.

6.2. Recommendations for Further Research

The contributions of this study pave the way for multiple avenues of future research. First, the validation of the proposed model for incorporating intersectional competence in nursing should include other stakeholders in healthcare, particularly service users and recipients of nursing care. While this study relies on nurses' professional experiences to identify practices that enhance their approach to individuals and communities, these accounts are inherently tied to individual beliefs and perspectives. Incorporating patients' voices would ensure the model's relevance and appropriateness. Additionally, involving more critical or dissenting perspectives, including individuals less familiar with intersectional approaches or health equity frameworks, could further explore the barriers and limitations of implementing this competence in practice. Second, future research should focus on the development and validation of tools to assess intersectional competence. These tools should objectively monitor competency development, tailored to specific contexts and stages of professional formation. Validated instruments would enable effective tracking of progress during both undergraduate education and professional practice, facilitating a structured pathway to achieving expertise in intersectional competence. Additionally, this research opens a field of exploration within nursing education context, suggesting a future research agenda that questions the pedagogical and evaluative strategies for training future professionals in intersectional competence. This calls for research from a pedagogical perspective, while also considering the managerial and leadership roles within educational institutions and teaching teams.

6.3. Implications for Policy and Practice

The results presented in this study provides clarity and specificity on the strategies and competencies to be acquired in the willingness to incorporate an intersectional perspective into practice, having implications for both clinical practice and education in nursing. Specifically, the social impact of this research spans to three levels. First, it aims to influence individual decision‐making by encouraging nurses to make conscious choices in care management and delivery, integrating an intersectional perspective. This supports autonomous nursing roles and enhances the value of care by addressing patients' specific axes of inequality. Second, the research proposes applying the intersectional model at a clinical level, fostering not only changes in practices and protocols but also a broader reflection on the purpose of nursing work. By highlighting the social value of nursing care, this approach seeks to increase nurses' visibility in public discourse. Third, at an academic level, by the definition of a conceptual framework for applying intersectionality to health competencies, this research supports critical revisions of teaching and learning processes in nursing education, facilitating the incorporation of intersectional competencies into curricula and promoting dialogue on professional roles. Combined, these impacts encourage collaboration across nursing roles, enhancing the profession's collective capacity.

7. Conclusions

The current social reality presents increasing complexity derived from its diversity and inequality, requiring a review of nursing professional practice that incorporates sensitivity to this complexity and specific tools to address it. While the results obtained show a broad consensus on the need to incorporate a change of perspective that breaks with the privilege of biomedical knowledge and allows for alternative responses to the social and health complexity of our environments, there is variation in how this should be done. Intersectional theory offers a theoretical framework for this review. This study aims to provide a model based on five interconnected dimensions that specify strategies for incorporating this theoretical framework into nursing professional practice.

Author Contributions

Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Ariadna Graells‐Sans, Gerard Coll‐Planas, Involved in drafting the manuscript or revising it critically for important intellectual content; Ariadna Graells‐Sans, Esther Insa‐Calderón, Montserrat Sanclemente‐Dalmau, Gerard Coll‐Planas, Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; Ariadna Graells‐Sans, Esther Insa‐Calderón, Montserrat Sanclemente‐Dalmau, Gerard Coll‐Planas, Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ariadna Graells‐Sans, Esther Insa‐Calderón, Montserrat Sanclemente‐Dalmau, Gerard Coll‐Planas.

Conflicts of Interest

The authors declare no conflicts of interest.

Peer Review

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16821.

Data Availability Statement

Research data are not shared.