Inclusionary othering: A key threshold concept for healthcare education

The concept of “othering” is frequently used in healthcare research to describe the way health professionals treat those who are “visibly” different, e.g. in terms of gender, ethnicity or age. The construct of othering, re-introduced into modern philosophy by de Beauvoir (1949), is defined here as: the view and behavior when a person, or group of people, are treated as essentially different and, possibly alien, from oneself. We posit that othering also happens in healthcare between healthcare professionals and patients/ service users based on the premise of “having” or “not having” biomedical knowledge. Othering may lead to stigmatization and has been shown to result in inequalities in healthcare services provision, and a reluctance by patients and service users to accept health information from healthcare providers. The aims of this paper are to, first, discuss how othering may inadvertently be fostered in healthcare students and, second, to provide suggestions on how to reframe othering, from exclusionary to inclusionary othering, and, third, by illustrating how inclusionary othering as a threshold concept can be embedded within a healthcare curriculum. We will conclude by discussing areas for further development in practice. A core skill in terms of preventing othering is empathy, which is considered the foundation of a biopsychosocial model to healthcare. Maintaining a biopsychosocial approach at the center of healthcare curricula is a complex challenge for educators. While the biopsychosocial model and the development of empathy underpin most healthcare curricula, research has shown that empathy tends to decrease in students while attending healthcare education (Nunes et al. 2011). We posit that one of the reasons for this decrease in empathy is the possible inevitability and pervasiveness of the biomedical model in healthcare education. Students must come to grips with the complexities of physiology, anatomy, and pathology. The requirement to attain essential knowledge in the biological sciences takes up a considerable amount of time, often leaving insufficient time to address the development of other attributes such as empathy. In addition, traditionally, softer skills such as empathy and concepts of health tend to be taught separately due to modularization of the curriculum. While not intended, this approach reinforces a biomedical model rather than the biopsychosocial approach advocated in most healthcare programs leading to a “hidden curriculum” (Martimianakis et al. 2015). This hidden curriculum is based on a combination of a biomedical model, with its emphasis on experts, i.e. those with specialist biomedical knowledge, and the developing identity of students to become healthcare professionals, will, inherently, bring a sense of “othering” of patients and service users. We propose that, while it takes a long time to make visible and change the hidden curriculum which leads to othering and a decrease in empathy, the negative impact on the power relationship with patients/service users should and can be addressed more immediately in healthcare education. We recommend that healthcare programs use “inclusionary othering” as a threshold concept to positively frame othering developed during the course of students’ education. Canales (2010) posits that there are two types of othering: inclusionary and exclusionary. The type of othering determines the resultant power relationship between health professional and patient/service user. Canales states that exclusionary othering “often uses power within relationships for domination and subordination” (p. 19). In contrast, inclusionary othering “attempts to utilize power within relationships for transformation and coalition building” (p. 19). Inclusionary othering, therefore, provides us with a concept to frame the othering taking place during healthcare education and helps us to engage students in their learning and supports them to transform exclusionary othering relationships with patients/service users into inclusionary ones. We propose that the concept of inclusionary othering is a “threshold concept” (Meyer and Land 2003). Threshold concepts are concepts which represent a “transformed way of thinking, or interpreting, or viewing something”. Threshold concepts are transformative, irreversible and integrative. This transformation is often considered troublesome and can take place over a short or more protracted period of time. We posit that inclusionary othering often is a troublesome concept for students’ in terms of their changing identity and the complexity and application of biological knowledge. Furthermore, we suggest that the transformation to inclusionary othering takes place over a protracted period of time as it is not merely the understanding but the praxis of inclusionary othering which is core to this threshold concept. An area where we observe students on a prequalifying healthcare program grappling with the impact of othering on power relationships with patients/service users is health promotion. One of the central tenets of health promotion is the need to use approaches which are suitable to the context and nature of the target audience. To facilitate health behavior change, health promotion requires a collaborative approach between healthcare professional and patient/service user, where the healthcare professional uses