From Cultural to Structural Competence: Reframing Transcultural Nursing Through Intersectional Social Justice

Introduction

The analysis of health disparities in nursing care is undergoing a conceptual shift through the integration of structural competence, intersectionality, and decolonization. Together, these frameworks move practice beyond individualistic, culture-centered paradigms toward critical engagement with institutional and political forces that perpetuate inequity. This shift requires not only reframing the problem from one of “culture” to “structure” but also committing to care that is substantively informed by structural realities in practice and education. Nursing has long aligned itself with equity, dignity, and human rights. Yet health inequities persistently harm marginalized populations, revealing structural failures embedded in societies and social institutions, including health systems.

Traditional cultural competence models have contributed to transcultural practice by improving communication and mutual understanding to improve care for diverse populations. Evidence from nursing education initiatives, including lesbian, gay, bisexual, transgender, and more (LGBT+)-focused curricula, demonstrates the value of culturally competent approaches while also revealing their limitations when institutional, policy, and systemic barriers remain unaddressed. However, these frameworks can inadvertently compress the complexity of inequity into simplified cultural traits or monolithic group identities. In addition, such frameworks can inadvertently drop recognition that structural inequalities shape health behaviors (Braveman & Gottlieb, 2014). Complementary approaches that foreground broader determinants of health and disease are therefore necessary.

Intersectionality, first articulated within Black feminist scholarship by Crenshaw (1989) and further developed by Hill-Collins (1990), provides a framework for understanding how multiple social identities, such as race, gender, sexual orientation, ethnicity, class, disability, and age, intersect with systems of power, including racism, sexism, heteronormativity, classism, patriarchy, and colonialism. From the early 2000s onwards, intersectionality has been increasingly applied within public health research and practice to examine how structural inequities are produced, experienced, and sustained across populations. These intersections create unique and intertwined experiences of privilege and oppression. Rather than treating these forces as separate and additive (Hill-Collins, 1990), intersectionality emphasizes their mutual constitution, which produces, at times, forms of harm greater than the sum of individual factors.

Empirical nursing research illustrates that intersecting identities, particularly sexual orientation, gender, and other marginalized social locations, are constituted through organizational cultures and policy regimes, rather than existing independently of them, thereby reinforcing the need for intersectional analyses that move beyond descriptive identity categories toward critical engagement with structural power. In nursing, intersectionality provides a valuable lens for understanding health status, access to resources, and historical context. When applied superficially, however, it risks becoming a simple listing of identity categories without deeper analysis of power, structural determinants, or political critique (Bowleg, 2023; Sherman et al., 2023). To avoid this, nurses should employ intersectionality to interrogate underlying processes such as institutional power, structural exclusion, and social determinants, rather than limiting its use to describing disparate outcomes.

Decolonization recognizes the enduring influence of colonialism, empire, and racism on social institutions and seeks alternative visions that re-center perspectives of historically oppressed and marginalized peoples (McGibbon et al., 2014). Modern nursing’s theoretical and structural foundations have been shaped by Eurocentric hegemony and sustained through systemic racism and the privileges of whiteness, heterosexuality, and patriarchy—forces that have long silenced critiques of structural injustice. Recent assessments of transcultural nursing and cultural competence highlight limitations in addressing decolonization when the focus remains on micro-level nurse–patient interactions. Thus, decolonization in nursing is an iterative process that exposes, challenges, and works to overcome the ongoing impact of colonial practices.

Implementing Intersectional Structural Competence

Structural competence reframes explanations of health disparities by offering a practical and pedagogical framework to intervene on systemic forces identified by intersectional and decolonial analyses (Bowleg, 2023; Metzl & Hansen, 2014). It develops the language, care practices, and interventions required to reduce inequities at community, institutional, and policy levels, and it critiques deficit-based teaching and clinical practices. Bowleg’s (2023) framework for structural practice provides 10 concrete steps that nurses can use to translate intersectional and structural insights into actionable care. These steps guide practitioners to move beyond cultural competency by critically examining how institutional, political, and economic forces shape health outcomes, rather than focusing solely on individual behaviors or cultural traits.

The steps include recognizing structural determinants in clinical encounters; examining social and institutional policies; identifying and challenging structural barriers; engaging in community partnerships; integrating structural humility into practice; advocating for policy change; using intersectional data to inform care; fostering reflexivity and self-examination; promoting equity in resource distribution; and embedding structural competence throughout nursing education and research. By adopting these steps, nurses can center structural determinants in their practice, address root causes of health disparities, and operationalize equity-oriented care at multiple levels, from the clinical dyad to institutional and policy arenas.

In practical terms, intersectionality, social determinants, and decolonization can be operationalized across multiple levels of nursing practice. At the clinical dyad level, nurses can integrate structural assessments into patient encounters, moving beyond individual cultural traits to explore how social and institutional forces shape health. In interprofessional care teams and patient handoffs, practitioners can ensure that information about structural barriers and social needs is communicated and acted upon.

At the institutional level, clinics and health care sites should analyze data using intersectional lenses—going beyond single-axis identities—and develop policies and services that respond to social determinants, including referrals for housing, food security, and other resources. Finally, broader advocacy efforts must shift from single-axis policy fights to intersectional policy initiatives that challenge colonial legacies and structural inequities, ensuring that reforms are inclusive and transformative. By embedding these approaches at each level, nursing can advance equity and justice in both care delivery and policy (see Figure 1).

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Figure 1.

Integrating Intersectionality, Structural Competence, and Decolonization to Advance Health Equity.

Discussion

As shown, intersectionality demonstrates that racism, classism, ableism, heteronormativity and heterosexism, and other forms of oppression are interconnected, creating compounded burdens. This raises two critical questions for nursing: What are the inequities we observe, and how do we intervene at the institutional level? Structural competence offers a pathway to answer the second question by translating intersectional insights into action—such as revising organizational policies, advocating for equitable resource distribution, and designing care plans that account for community-level determinants. Moreover, decolonization reinforces this approach by asking: How do we dismantle colonial legacies embedded in education and practice? A practical response is to integrate structural determinants of health throughout nursing curricula and embed critical reflection into clinical training. Together, these frameworks move nursing from awareness to systemic change, ensuring that equity and justice are not only discussed but operationalized in everyday practice.

The relationship among structural competence, intersectionality, and decolonization—and the notion of compassionate nursing care—rests on praxis (action and reflection) grounded in a commitment to social justice. This entails a radical shift from individual-centered therapeutic approaches to a systemic and relational vision of health. Compassionate care requires critical consciousness: a deep understanding of how power and resources are distributed in society, coupled with action to challenge the status quo. Reflexivity and structural humility are essential—rigorous self-examination of implicit biases, privileges, and institutional positioning to prevent prejudiced policies, practices, and educational approaches. Framed intersectionally, compassionate care urges a move away from deficit-focused research and practice toward strength-based approaches that recognize community competencies, resources, and resilience (Papadopoulos, 2018).

Recommendations

To move beyond singular approaches to intersectionality and cultural competence and achieve genuine health equity, structural change across research, education, and practice must be prioritized. Research can shift from descriptive, deficit-focused observational studies toward developing, understanding, and evaluating interventions through a clear intersectional lens. Strength-based work on protective factors and resilience should be emphasized, with transparent definitions and operationalization of intersectionality. Curricula require fundamental restructuring to integrate structural competence throughout, educating future professionals about systemic factors that cause harm. Educators can adopt critical pedagogies that empower students to confront underlying social injustices and move beyond passive, one-directional classroom models, including formal, funded partnerships with communities so that local knowledge is central and respected—fulfilling the promise of decolonization and reconciliation.

In clinical practice, nurses must assume active roles in policy advocacy and institutional accountability. This includes using intersectional frameworks in diversity, equity, and inclusion analyses from the outset, moving beyond aggregate metrics to examine data across multiple identity axes and expose cumulative inequities faced by marginalized groups. As the largest segment of the health care workforce, nurses can leverage their position to advocate for structural and policy interventions that address housing, employment, and environmental injustice—dismantling colonial and racist systems that generate illness—and thereby translate principles of structural competence into measurable outcomes of social justice.

Ultimately, the integration of structural competence, intersectionality, and decolonization represents more than a theoretical shift; it offers nursing a path toward transformative, justice-oriented care. By embedding these frameworks firmly in research, education, and practice, the profession can finally fulfill its long-standing commitments to equity and human dignity while tangibly improving health outcomes across diverse communities.