Inclusion: A Concept Analysis

Inclusion is a word that is mentioned relatively frequently in literature, most often in academia or education. However, the word inclusion often changes meaning depending on where the research is coming from. Furthermore, the term inclusion is frequently confused with the term diversity and even used synonymously. These terms do in fact have different meanings, and one of the aims of this concept analysis is to demonstrate the difference. The main purpose of this concept analysis is to form a concrete definition of the word inclusion that has defining attributes and fits multiple different disciplines. Even in areas as different as music and engineering, the term is used similarly and has very comparable antecedents, attributes, and consequences.

John Wilson’s eleven steps to a concept analysis was decreased to eight steps by Lorraine Walker and Kay Avant in their sixth edition of “Strategies for Theory Construction in Nursing”. Walker and Avant start simply with selecting a concept. The first step involves finding a relevant concept to analyze. After some research on the term inclusion and an inability to find a consistent, concrete definition, it was decided that this was a great place to start. The aim of the concept analysis was determined in the second step, which was to form this universal, concrete definition of inclusion that could be applied in many different disciplines. This helps to focus attention on exactly what is intended to make the results of the effort, the “why” [1] (Appendix A).

Apendex A:Concept map.

The third step of Walker and Avant’s [1] methodology is to identify all uses of the concept that can be discovered. Many of the uses are related but have a completely different meaning, such as inclusion bodies in microbiology, rigid inclusion in geomechanics, and inclusion criteria in research. The related terms that are included in the literature review are social inclusion, financial inclusion, inclusive culture, educational inclusion, inclusion climate, inclusion activism, inclusion health and trans inclusion. According to Walker and Avant [1], the defining attributes are the heart of the concept analysis (p. 173). The fifth step of Walker and Avant’s [1] methodology is to identify a model case. The model case described in the body of the paper best exemplifies all of the attributes that encompass inclusion. The other cases outlined in the sixth step of Walker and Avant are the contrary case, the borderline case, and the related case. The contrary case possesses none of the attributes that the model case does and, therefore, showcases what a complete absence of inclusion would look like. The borderline and related cases both possess some attributes of inclusion, however, do not encompass all of them. Looking at these different cases helps to make better judgements about which defining attributes or characteristics have the best fit. The borderline case contains most of the defining attributes, but usually differs substantially in one of the attributes. Related cases do not contain all of the attributes either but are in some way connected to the main concept. The related case aids in the understanding of how the main concept fits into the network of concepts surrounding it [1].

The final two steps of the Walker and Avant [1] methodology help to solidify the full meaning of the concept. Step seven is identifying the antecedents and consequences of the term. Antecedents are the incidents that must take place in order for the concept to occur. Consequences are the incidences that occur as a result of the concept. This was done regarding all of the disciplines, and the antecedents and consequences that were mentioned most often were selected [1]. For the eighth and final step, empirical referents were identified. Empirical referents are measurable critical attributes, such as scales or surveys. These can also be categories of phenomena that, by their existence, demonstrate the occurrence of the concept itself. Sometimes these empirical referents are the same as the concept’s defining attributes, as is the case in this concept analysis [1].

An extensive literature review was conducted in order to identify all uses of inclusion and compare and contrast the definitions across multiple different disciplines. The search turned out to be very heavy in the education department but spanned across many different occupations. The occupations include nursing, elementary education, special education, higher education, workplace concerns, social workshops, women in engineering, construction, music, arts and humanities, finance, and even architecture. The terms seen multiple times that involve the word inclusion are social inclusion, financial inclusion, inclusive culture, educational inclusion, inclusion climate, inclusion activism, inclusion health, and trans inclusion. Even when used in these different contexts, the word inclusion has many similarities across disciplines. Most of the articles synthesized are systematic reviews, but there are also a few quantitative and qualitative studies as well. The one very clear aspect found when reading about this term across different disciplines, is that inclusion is always something to strive for and results in positive outcomes (Appendix B).

Apendex B:PRISMA..

Inclusion in other contexts

In the literature search there are a few articles that mention inclusion, but not necessarily in the same context as what is meant for this concept analysis. For instance, microbiology mentions inclusion bodies as dense proteins that contribute to a person’s DNA. This term is also mentioned in veterinary literature in reference to a viral infection that affects chickens and can lead to tumors. The specific virus mentioned that possessed the inclusion bodies was Newcastle disease [2]. In geomechanics, the term utilized frequently is rigid inclusion. This term describes a pile supporting embankment to address the problem of soft soil. The rigid inclusion is an actual beam that is inserted into the soil. This reinforcement technique is revolutionary in addressing low quality, soft soil that is also mentioned in geotechnical engineering [3]. Specific to agriculture, inclusive dialogue is mentioned by the United States Department of Agriculture (USDA). This inclusive dialogue creates a form of sustainable agriculture based on a resilient ecosystem. The objective is to facilitate inclusive dialogue in the United States (US) on sustainable food systems and is important for informing nano-agricultural food innovation [4].

The most commonly mentioned form of inclusion that is not exactly in similar context but definitely relevant is inclusion criteria in research. This term actually came up so frequently in the literature search that it had to be negated from the search criteria. Inclusion criteria in research often refers to demographics or characteristics of a population or phenomenon. Inclusion criteria define the key descriptors of a target population that a researcher will utilize to answer the research question at hand. For instance, the inclusion criteria for this concept analysis encompasses articles with full text, abstracts and references available, published within five years, only in the English language, peer reviewed, in academic journals and do not only refer to inclusion criteria in research.

Inclusion in education

Education is the most prevalent subject area to use the word inclusion. Much of the literature refers to a concept called inclusive education and transformative learning, where all intellectual abilities are taught in one room. This differs from the past where many times classrooms were split up by ability levels, especially in high school education. One article in particular dive into the history of inclusion in education and defines the goal as “quality education for all, with the aim of advancing more equitable societies and improving the life chances of millions of vulnerable and marginalized people worldwide” [5]. The population that education is most often trying to include are people with intellectual disabilities.

Murdoch et al. [5] expresses that there is no universally accepted definition for the term inclusive education, mainly because it is a complex idea that has been influenced by medical advances, civil rights movements, and disabled individuals wanting to have a say in their own education. Key documents that influenced the history of inclusion include the Warnock Report from the United Kingdom in 1978, “No Child Left Behind” after that in America, and then the United Nations Educational, Scientific and Cultural Organization (UNESCO) “Education for All” initiative also took off. All of these initiatives raised awareness about whom should be included in the classroom. In the 1970s and 1980s, many students were unnecessarily excluded from educational opportunities. They often received an alternative sort of education in special schools, which had a life-long limiting effect on present and even forthcoming opportunities [5].

Armes et al. [6] describes engagement and student expression as consequences of inclusion. The musical education of students with disabilities is largely shaped by the Individuals with Disabilities Education Act (IDEA) passed in 1975 by President Ford and updated in 1997. IDEA specifies that individuals with disabilities should not only be included, but their education should be individualized to meet their needs [6]. Specific to elementary education, authors Cambridge Journal of Education describes inclusion as a sense of belonging. A lack of inclusion in a classroom creates barriers to learning, including participation and achievement. Within an inclusive classroom, learners should feel “valued and accepted when their opinions are views are respected” [7]. Specific to education of Speech-Language Pathologists, it has been found that it is easier to support inclusive classrooms with co-teaching and collaboration among faculty [8].

Inclusion in the workplace

Many of the articles included in this analysis refer to an improvement in the workplace through inclusion. However, many of the studies mention both diversity and inclusion, but only outline strategies for diversity. The terms are utilized synonymously many times, even though their meanings are very different. This improvement in the workplace varies across multiple different disciplines and usually involves training or a workshop. The main difference in the articles on inclusion in the workplace is the minority they are trying to include. The authors explore inclusion through race, disability, gender, age, occupation, and even personality traits. The common theme is how to make these groups feel included in order to increase productivity.

One article about inclusion in a behavioral health facility mentions that a lack of “standardized outcomes to measure innovation and productivity in the workplace poses a challenge for researchers to promote inclusion” [9]. The researchers believe that specific techniques should be adapted and individualized in order to meet the needs of all employees and create a sense of belonging [9]. In business, the term inclusion climate is often used. This is defined as the “representation of marginalized group members and the elimination of discrimination against them” [10] and is the main goal of any training or workshop. The consequences of this training to promote an inclusion climate include authentic belonging and justice.

Inclusion in nursing

Many of the studies promoting inclusion in nursing are similar to the workplace concern articles mentioned in the workplace section above. Inclusion in nursing is represented as a desired outcome that takes effort and support to culminate. The most common consequences of inclusion in nursing are a sense of belonging and cultural competence. It is almost an equal split between the number of articles dealing with racial inclusion than those of gender identity inclusion, making nursing and education the most prominent areas that heavily focus on gender equality in recent literature. Name and pronoun mishaps are the impetus of many microaggressions interfering with an inclusive environment [11]. To provide some historical background of inclusion in nursing, in 1986 the American Nurses Association (ANA) published its first intention to expand workforce inclusion to better reflect the racial and ethnic demographics of US populations. The more recently updated Title IX of the education amendments is a federal civil rights movement to prohibit discrimination based on sex or gender in educational programs or activities [12].

Another term related to inclusion in nursing is inclusion health. This refers to people who are excluded more socially and possess risk factors for characteristics such as poor health, poverty, violence, or even complex trauma. This phenomenon is usually mentioned from a public health nursing perspective and puts a heavy focus on accessible care that results in better health outcomes for all [13]. Zajac [14] emphasize the importance of inclusion with diverse faculty that are essential to the retention of a diverse student population. The author recommends starting with the nursing syllabus, which must exhibit “inclusiveness, belonging, supportive course policies, and approachability, with statements that motivate and portray collaboration” [14]. Specific to nursing management, this can be done by including diversity, equity, and inclusion (DEI) in the mission and values of the institution [15].

Inclusion in arts and humanities

Inclusion is abundant in the arts and humanities literature and has many similarities across the spectrum of disciplines. Specifically in library education, inclusion is seen as a state where all are able to thrive. Very much like financial inclusion, the result is empowerment and participation. Social inclusion is mentioned as a more specific form of inclusion [16]. In the musical realm, inclusion typically pertains to gender identity and the goal is to promote a culture of change. This requires awareness, education, and the will to support equality, justice, and equity [17]. Philosophical papers touch on the “trans inclusion problem” and how it is challenging to find an appropriately inclusive concept of the word woman. One article sees inclusion as a type of feminism and mentions the term social inclusion, much like the literature from medical education and library education [18].

A remarkable article out of Geostrata Magazine focuses on the specific difference between inclusion and diversity. The emphasis is on the fact that diversity cannot bring value to a team without the concept of inclusion. The author critiques the idea of diversity training in that it does not overcome conscious bias, which is the main barrier to inclusive leadership. The similes in this article are profound, such as “diversity is being invited to the party; inclusion is being asked to dance” [19]. Pehlivan [19] further describes diversity as “inviting dancers with different dance styles to the party; inclusion is empowering them to dance”. This author establishes empowerment to be a main attribute of inclusion, much like in finance and economics.

Inclusion in engineering

The term inclusion in engineering is found most abundantly in civil engineering and construction literature. Inclusion refers to the acceptance of everyone regardless of age, gender, experience level, race, social status, or education. Similar to nursing literature, the concept of DEI is mentioned in more than one article. Gender inclusion is found more in engineering literature than nursing literature, most likely due to the fact that females are a minority in engineering and construction [20]. Similar to other disciplines, engineering journals mention inclusion as an initiative that requires training and is appealing to those in management positions. In engineering, inclusion is about “creating a culture where all involved can participate and influence” [21]. This results in a positive impact of diversity for a competitive business advantage.

Francis [21] illuminates the importance of inclusion with the social exchange theory, explaining that people often make decisions by subconsciously determining the risks and benefits of a relationship in order to maximize their benefit. While diversity in race is mentioned in the engineering literature, most of the articles on inclusion advocate for more women in engineering. Social support and opportunity are among the most important features needed to promote this sense of inclusion [22]. Strategies to increase inclusion specific to education in engineering include creating an environment where individuals feel psychologically safe and fostering a sense of respect and value. This can be achieved through reflection [23]

Antecedents of inclusion

After synthesizing literature from all disciplines, the proposed antecedents of inclusion are disability, marginalized groups, diversity, knowledge, support, collaboration, and training. Nursing and education are the two areas that list the most antecedents, most likely because much of the literature focuses on training programs to increase diversity and inclusion. The most common antecedents found in the education literature are productive struggle, disability, building community in the classroom, empathy, support, marginalization, differing socioeconomic statuses, diversity, commitment, patience, motivation, resources, bias, training, trust, security, collaboration, sustainability, participation, value, funding, knowledge, advocacy, planning, and reflection. The literature on education includes all of the proposed antecedents for inclusion, as the attributes from education are all seen again in the other disciplines.

Nursing literature identifies very similar antecedents to education, but nursing adds stakeholder engagement, awareness, identification of affected populations, understanding, experience, recruitment, discourse, opportunity, and microaggressions. The microaggressions mentioned are in reference to misgendering nursing students or using the wrong pronoun for the students. Inclusion in other healthcare backgrounds, such as social work, mention antecedents such as civic education, social enterprise, and freedom. Articles specifically tailored to the business workplace only mention antecedents that describe the type of diversity that would need to be included, such as age groups, races, ethnicities, gender identities, other marginalized groups, and occupation.

The literature is rounded out by inclusion in engineering, which also focuses on engineering education and training in order to obtain the goal of complete inclusion. The articles from engineering sources are more technical and mostly cover branches of engineering that do not include many women, such as civil engineering. The unique antecedents to this literature that do not fit with the other disciplines are prejudice, unconscious bias, acceptance, and emotional intelligence. It was surprising to not see empathy and emotional intelligence mentioned in more articles given the definitions of inclusion in each area. In all, what is required to reach the goal of inclusion in any discipline involves some sort of marginalization that requires knowledge, support, collaboration, and training to execute.

Consequences of inclusion

The consequences of inclusion are social justice, transformation, participation, and engagement. These qualities are the result of implementing inclusion in any area or discipline. Specific to education, consequences of inclusion are transformative learning, opportunity, participation, improved performance, respect, value, productivity, success, equity, compassion, sustainability, a democratic society, entitlement, a unified vision, liberation, truth, self-reflection, and incorporation. All of these consequences are positive attributes, concluding that inclusion leads to positive outcomes across the board. Unlike the antecedents, only one of the consequences comes from the education literature. On other hand, business workplaces report increased productivity, creativity, and problem-solving as a result of inclusion efforts.

An article specific to publishing and editing reports a workflow transformation, fair and equitable representation, and the desire to learn. Nursing literature outlines consequences of inclusion to be engagement, motivation, self-efficacy, satisfaction, confidence, cultural sensitivity, improved health outcomes, an equitable learning environment, experience, information retention, social equity, and social justice. Nursing literature focuses more on patient outcomes and feelings of staff once an environment of inclusion is implemented, while finance and economics focus more on reducing poverty and gender inequality. Specified consequences of inclusion in finance are gender empowerment, economic growth, strategy, legislation, regulation, and increased access.

While nursing reports improved patient outcomes through inclusion efforts, agriculture similarly outlines safe and efficient products. The arts and humanities literature define the consequences of inclusion to be justice, liberation, equality, equity, support, self-identification, social justice, knowledge, innovation, motivation, and trust. These consequences are very similar to those found in educational literature. Lastly, engineering uncovers the consequences of inclusion to be acceptance, respect, participation, skills utilization, success, reduction of turnover, psychological safety, authenticity, and engagement. One article in the literature on higher education thoughtfully described inclusion as often “simply a change of language in the discourse of good intentions” [24].

Attributes of inclusion

According to Walker and Avant methodology, the attributes of a concept help to form the definition. In the case of inclusion, the defined attributes found in many disciplines are belonging, equity, cultural competence, respect, and equality. The literature on education really focuses on quality over quantity of time, and the ability to transform an institution through inclusive efforts. Furthermore, education literature ascertains attributes of inclusion to incorporate a sense of belonging, empathy, leadership, understanding, advocacy, engagement, student expression, value, respect, equity, social justice, equality, and collaboration. Some of these attributes are listed as consequences in other areas, such as nursing.

Attributes of inclusion in behavioral health and the workplace in general include innovation, productivity, authentic belonging, and justice. Agriculture and farming actually see innovation as an attribute of inclusion as well, even if in a completely different context. The attribute seen the most in all of the literature is very clearly belonging. Specific to nursing, this attribute is seen as well as cultural competence, cultural awareness, cultural humility, social justice, respect and dignity. Establishing culture in nursing is emphasized as very important. Social work, finance and arts and humanities see inclusion as proactive communication, increased knowledge, empowerment, cultural competence, equity, and stability. Engineering literature, primarily in the civil engineering sector, sees similar attributes of inclusion such as diversity, equity, social justice, acceptance, respect, belonging, reflection, cultural competence, and social exchange.

Definition of inclusion

Inclusion is a feeling of respect and belonging with equity to create a sense of engagement, social justice, and transformation. Almost all of the articles in the educational literature on inclusion offer a definition, however it differs depending on which level of education. For instance, elementary education defines inclusion as “organizational efforts to make individuals of all backgrounds feel welcomed and equally treated” [25]. Many of the authors use the terms inclusion and diversity interchangeably, but one article specifically makes it a point to define both and show the clear difference, such as diversity “including any dimension to differentiate groups and people from one another” [25]. Diversity is actually an antecedent to inclusion, not a synonym or attribute as many seem to believe. Specific to early childhood education, inclusion is defined as “access to a variety of learning opportunities, individualized modifications that facilitate participation with adults and peers, and systems-level supports that undergird classroom efforts” [26]. Articles specifically on catholic education express a big concern in the lack of inclusive efforts. Many catholic schools report no inclusion of students with disabilities. In order to mitigate this, a concept called least restrictive environment (LRE) is maintained [27].

Inclusion in education is often discussed in regard to disability, but many other disciplines see inclusion as a way to fix racism and prejudice. Business articles mention a concept of inclusion climate, which is defined as the “representation of marginalized group members and the elimination of discrimination against them” [10]. A similar term seen in other areas is inclusion activism, which is defined as “an intentional effort to ensure participation and access as well as leadership opportunities to people of all backgrounds, at all career stages” [28]. The medical fields focus not only on social inclusion, but inclusion health as well. This is to describe patients that are socially excluded, often with multiple health risk factors combined with social concerns [13].

Empirical referents

Thirteen quantitative studies and six qualitative studies are included in this concept analysis. There are not many scales to measure inclusion, which pointed to a gap and potential opportunity for further inclusion research. Empirical referents are referred to as measurable critical attributes, often in the form of scales or surveys. However, these empirical referents can also be categories of phenomena that demonstrate the occurrence of the concept itself [1]. In the model of inclusion, this refers to the attributes themselves-- belonging, equity, cultural competence, respect, and equality. One of the quantitative studies in education literature utilizes the Scale of Perceptions on Inclusion in the University (SPIU). The SPIU aims to evaluate the culture, policy, and practice of educational inclusion at the collegiate level. This study validates the SPIU scale and found that universities must play a substantial role in endorsing the change of ethical and social mindsets and practices in order to promote inclusion [29].

An 80-item social inclusion/exclusion scale is utilized to increase knowledge in social workers about the concepts of social inclusion and civic education to improve mental health in older adults. The study found that the higher the older adult scored on the depression scale, the more likely that individual was to feel socially excluded. Hsieh [30] recommend prioritizing social inclusion services to elder adults that focus specifically on mental health inclusion and improvement efforts. Lastly, a scale constructed by Bude and Lantermann in 2006 is utilized to analyze social inclusion of women in public transportation. The scale consists of four items, “I feel excluded from society”, “I am worried to be left behind”, “I feel that I am left out” and “I feel like I do not really belong to society”. The study was performed in Pakistan and aims to increase social inclusion of women within urban planning and development [22].

Application of cases

Walker and Avant methodology stresses the importance of cases in the analysis of a concept. The model case contains all of the proposed attributes of the concept and is said to be a perfect representation. The contrary case is the opposite, where none of the attributes are exhibited and represents a contrasting idea of the concept [31-36]. The borderline case contains most of the defining attributes, but usually differs in one or two of the qualities. In the borderline case below, the attributes of belonging, equity, cultural competence, and equality are exhibited, but the case lacks the attribute of respect. Related cases do not contain all of the attributes either but are connected to the main concept. The related case facilitates understanding of how the concept of inclusion fits into the network of concepts surrounding it. In this related case, the relationship between diversity and inclusion is explored [1].

Model case

Professor Harris teaches undergraduate nursing at a fully inclusive university. Two students in her class receive accommodation services from the university to support their diagnoses of Dyslexia and Autism. This includes special notetaking services provided by the university as well as extended time on examinations. In the nursing cohort there are over twenty ethnicities and cultures represented; this can be said of the faculty as well. All the university faculty have been trained on topics such as diversity, disability, and marginalization. There are also many resources available to both the faculty and students in an inclusion toolkit [37-39]. The students and faculty feel as though they all belong and work together as a family with mutual respect for one another.

Professor Harris suggests the university considers exploring further cultural competence training to support new faculty and students during ongoing admissions and to sustain the current practice. In addition, student government has started a committee that looks at social justice and equality issues throughout the country and brings education on these current events to their fellow classmates [40- 42].

Contrary case

Professor Smith teaches graduate nursing at a public university. There is a student in his class that has a medical condition where they need access to food and drink at all times, even during examinations. Due to this being against the university policy, Professor Smith denies the student accommodation. The entire cohort of students are white females in their thirties. Many students have asked Professor Smith to include education on topics such as social justice and equity, but he is not knowledgeable in these areas and the administration does not have any resources available to help him. Lectures often end in turmoil over different viewpoints and backgrounds as they apply to the topics they are learning about. Admission rates are at an all-time low, faculty retention rates are at their worst in years, and morale at the university is poor [43-46].

Borderline case

Susan is an elementary school teacher at an inner-city school in Pennsylvania. Four students in her class meet with an aide daily to ensure comprehension, as English is not their first language. Susan’s class has multiple ethnicities represented, and because of this, she has received training on diversity and disability in students. The children are all very close with one another, but the English as a Second Language (ESL) students feel that Susan does not speak to them in the same tone that she does the other students. The grading and assignments are all equal and fair, but the students have overheard other teachers talking about how much work it is to include the ESL students.

Related case

Judy is attending an engineering conference in Seattle, Washington. Thousands of engineers from around the world are invited to attend the conference and many RSVP yes. Turnout for the conference is a complete success, with many different areas of engineering being represented, almost as many women in attendance as men, and over 50 different countries and ethnicities represented. However, when looking at the conference pamphlet, Judy notices that all of the education sessions are delivered by electrical engineers. Furthermore, all of the electrical engineers are white males. While the conference has diversity, it lacks inclusion. None of the diverse attendees have been empowered to lead a session.

Implications for nursing education, practice and administration

Inclusion in nursing is not only significant to education, but in practice as well. Inclusive patient care that starts with the nursing curriculum to ensure both equality and cultural competence in our future nurses is imperative. Starting inclusive efforts during school has a domino effect once these nurses are in practice. Nurses are taking care of patients from different backgrounds, beliefs, ethnicities, gender identities, disabilities, and more. Making these patients feel as though they are respected and belong is how we build a trusting relationship.

The inclusive training programs outlined in areas like finance, engineering, and education can benefit any field. Inclusion is a positive way to implement meaningful diversity. Forming a concrete definition of the word inclusion not only guides future inclusion efforts, but further demonstrates the difference between diversity and inclusion. By increasing knowledge, support, training and collaboration, nurses can give their patients a sense of belonging and equity that goes along with the respect they all deserve.

This concept analysis forms a concrete definition of the word inclusion that has defining attributes and fits multiple different disciplines. Even in areas as different as agriculture and nursing, inclusion is used similarly and has very comparable antecedents, attributes, and consequences. The terms diversity and inclusion are often used interchangeably in literature, although they do not have the same meaning. The word inclusion is utilized mainly in reference to education; however, it applies to many different areas. The six databases searched to form this concept analysis rendered 44 articles that are synthesized and reported using the Walker and Avant methodology. There are not many scales to measure inclusion, which points to a gap and potential opportunity for further inclusion research. Implications for nursing include the need for inclusive patient care that starts with the nursing curriculum to ensure both equality and cultural competence in our future nurses. In conclusion, the concept of inclusion is a feeling of respect and belonging with equity to create a sense of engagement, social justice, and transformation. Further research is recommended to explore more ways to measure inclusion and further differentiate diversity from inclusion.

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