Socially marginalised patients with addictive problems are characterized by multi-morbidity including both somatic and psychiatric diseases and have a significantly higher degree of mortality and reduced life expectancy of 19 years compared with the Danish background population [1-3]. The healthcare systems often encounter complex challenges relating to health inequalities that are difficult to resolve. Socially marginalised patients are often stigmatised and perceived as complex patients when admitted to somatic hospitals [3, 4]. Most modern healthcare settings are familiar with social workers [5]. However, a health-related nursing approach (social nurse), situated at somatic hospitals, aims to ensure socially marginalised patients the same rights and access to care, treatment and dignity as the background population is, so far, a novel approach. It is based on in-depth knowledge of socially marginalised patients and competences into rehabilitation that may diminish health inequalities [3]. Further insight into the potential benefits of this social nursing approach is needed.

Social marginalisation and health inequality are global phenomena representing major challenges in today’s societies [1-3]. Social marginalisation refers to processes due to which some individuals and groups face systematic disadvantages such as poverty and poor housing and socioeconomic conditions that may, in turn, lead to health inequalities [4, 2]. Health inequality is defined as differences in health resulting from a systematic lack of resources; they are thus socially produced and unfair [5].

European studies have shown a relationship between socioeconomic deprivation and increased mortality [6]. In Denmark, the estimated number of socially marginalised persons is around 180,000 persons [7]. Their overall health condition is inferior to that of the general population, as illustrated by a 5-6-fold increased number of emergency department visits and a mean life expectancy that is reduced by 19 years [8, 9]. Thus, social marginalisation and health inequalities are complex concepts painting a bleak picture of a population with a significantly increased risk of disease due to intricate life circumstances [10, 8, 9].

Reducing health inequalities and improving overall population health conditions are core goals in many countries [11]. The World Health Organization (WHO) highlights the need for health professions to act to tackle social and health disparities worldwide [12]. Studies indicate that socially marginalised individuals face several social stress factors complicating their coping with disease and reducing their ability to complete hospitalisation [13, 14]. Moreover, as patients, socially marginalised people often encounter barriers - e.g. healthcare providers’ poor knowledge of the effects of social marginalisation - that make it more difficult to achieve treatment and care goals. These studies highlight a need to combine a clinical focus with specific actions to handle these challenges. It has been suggested that the nursing profession may be in a position to address these challenges [1]. Hence, Reutter and Kushner (2010) argue that nursing has a mandate to promote health equity [15].

Internationally, numerous approaches exist. A British study argues that harm reduction as an overall approach in hospital settings may reduce health inequities by allowing consumption of drugs and/or alcohol as well as by providing access to clean needles and syringes during hospitalisation [16]. Furthermore, the authors stress that healthcare professionals lack the skills and ability to work from a harm-reduction perspective. They propose the implementation of a discharge programme designed to ensure that socially marginalised patients retain the improvement gained during hospitalisation post discharge [16]. A Taiwanese study concludes that nurses can be the key figures in working with patients suffering from harmful alcohol misuse. However, the study shows that nurses in hospitals lack knowledge and education to handle these tasks [17]. Moxley and Washington (2016) underline that working with vulnerable groups poses significant and unique challenges for nurses as they do not feel competent to identify marginalised patients’ needs. The study proposes collaboration between nurses and social workers to identify both health-related and social needs [18].

In Denmark, a unique nursing approach was introduced in 2006 to ensure more equal outcomes for socially marginalised patients in somatic hospitals [19, 20]. This initiative is based upon the principles of harm reduction and an appreciative inquiry and thus aims to assure a connection between society, everyday life and the patient [20]. The target population includes patients with substance abuse and/or alcohol consumption and patients at risk of social marginalisation admitted to somatic hospitals [20]. It is worth mentioning that The Danish healthcare system is tax financed and therefore free of charge for Danish citizens. Hence, hospital admissions does not depend on socio-economic status or insurance. A nurse working with this unique approach, a “social nurse” contributes with specific knowledge about marginalisation, disparities, health inequalities, pain and/or abstinence treatment, and with a profound understanding of the unique problems marginalised patients are often facing [20]. A social nurse has years of experience working with socially marginalised patients. Besides the social nurse has experience from the established healthcare system. A local evaluation has been conducted, indicating a positive impact for both patients and healthcare professionals [21]. Still, it remains unknown specifically what social nursing is and does. The present study aims to examine how social nurses describe and experience social nursing situated at somatic hospitals.

The study shows that social nursing is based on a unique expertise accrued through years of experience with marginalisation. By virtue of this unique expertise, the social nurse incorporates reflections on his or her experience with marginalisation into a health context. Hence, a professional approach to healthcare rooted in nursing experience emerges. This approach encompasses unique knowledge of marginalised persons’ often complex needs and life conditions. This approach is comparable to the patient-centred approach proposed by Guirguis-Younger et al. [14], where the nurse combines prior experiences with present practice. In doing so, the nurse becomes capable of identifying situations requiring immediate action and of prioritising the patient’s care needs [14]. In line with the patient-centred approach”, the social nurse’s unique expertise is instrumental in identifying and acting upon situations that could otherwise have become an obstacle and restricted the patient’s range of relevant treatment options.

The findings of the study also indicate that lack of knowledge of the consequences of marginalisation is common within the healthcare system. Such a lack of knowledge can create barriers for staff in their exercise of nursing and treatment. Concurrently, situations may arise in which the available treatment option does not make sense to the marginalised patient, who therefore often does not complete treatment. This is comparable to Guirguis-Younger et al.’s findings that suggest that healthcare professionals often lack knowledge of complex conditions such as multiple diseases and hard-to-solve social issues which unfold when marginalised persons are hospitalised [14]. In line with our findings, Guirguis-Younger et al. highlight that lack of knowledge creates neglect of needs, which may, in turn, result in mortality rates among socially marginalised persons being several times higher than those observed in the general population [14]. It is therefore essential that the social nurse draws on prior experience with and knowledge of social marginalisation integrates this into current nursing practice.

The close connection of social nursing to standard nursing is evident as social nursing is rooted in knowledge and experience gained while exercising both fundamental and specialised nursing tasks. Social nursing, therefore, requires a combination of specialist nursing knowledge and understanding of socially marginalised persons’ often multi-faceted problems that can make them unable to care for themselves and unable to satisfy their most basic human needs. Seiler & Moss described this kind of nursing as “the true art of nursing” [26], i.e. when the nurse provides healthcare and makes a difference to marginalised patients based on extensive knowledge and experience [26]. Seiler & Moss argue that this experience requires an encounter between nurse and patient characterised by an understanding that by virtue of his or her experience, the nurse has obtained great insight into the socially disadvantaged individual’s daily practice, which is an advantage for both parties [26]. The unique expertise described herein is thus in line with “the true art of nursing” and enables nurses to embrace a unique group with equally unique demands. Combining nursing with an appreciation of the characteristics of marginalisation enables the social nurse to serve as a link between the healthcare system and the socially marginalised patient. This link can ideally assure that the ward providing the treatment can offer dignified and complete services

In the present study, coordination of socially marginalised patients’ treatment courses was highlighted as one of the social nurse’s key tasks. Hence, adequate coordination was vital in diminishing marginalisation. Thus, a well-coordinated treatment course is based on the ideology that we need to embrace the entire human being. This ideology has limited clout in an output-oriented healthcare system where streamlining and acceleration are often perceived as being identical to good treatment, even if such an approach might limit the staff’s opportunity to gain insight into and therefore truly understand the patient’s complex situation. The study indicates that lack of or incorrect coordination can thus increase the risk of further marginalisation during hospitalisation. According to Seiler & Moss, healthcare professionals’ experience that it is difficult to act on coordination tasks related to the patient’s course. This may be due to several factors. Dr. Josephine Watson points out that the causes are likely related to the narrow perspective on the complexity of the patient’s situation due to lack of knowledge. According to Dr. Watson, this fosters stereotypical images of socially marginalised persons which can shift focus away from seeing the individual, thus, limit the opportunity to take a holistic approach. According to Dr. Watson, a holistic approach is essential in resolving tasks related to the marginalised patient [27]. According to Seiler & Moss, other causes are related to structural limitations such as finances, referral options, lack of suitable discharge locations and a general lack of knowledge [26]. Stereotyping fostered by the system can - according to Dr. Watson - be reversed through greater knowledge about marginalisation [27]. Seiler & Moss believe that this knowledge can make healthcare professionals better at handling structural limitations [26].

Thus, the social nurse’s coordination task is important in reducing marginalisation. Coordination of the marginalised patient’s treatment course requires considerable insight into the marginalised patient’s lived life and way of handling everyday life. The social nurse has such insight because of the knowledge he or she has acquired and because of his or her extensive professional networking. Hence, a holistic perspective becomes essential to achieving a productive collaboration between the hospital and the marginalised patient where understanding of the patient’s situation is integrated into the healthcare system’s provision of healthcare services.

The study indicates that the social nurse works according to a holistic and reflected perspective where social nursing is carried out with respect to any information that can be significant to the individual’s lived life and lifeworld. Meanwhile, the social nurse reflectively handles information that could be important to the admission course and contribute to the nurse’s ability to see the marginalised patient as a whole person.

Dr. Watson argues that healthcare professionals who grasp what social marginalisation can mean to health are capable of offering a wide-ranging and holistic treatment and become advocates for a healthcare system that seeks to diminish marginalisation [27]. To diminish marginalisation and ensure access to care and treatment for all who experience injustice and inequality in health are, according to Professor L. Kushner, within “the nursing mandate”. Kushner argues that through this mandate, nurses can achieve change through collective action, advocacy and empowerment of vulnerable communities and thus engage in the struggle against inequalities [15].

Social nursing’s holistic and reflective approach is thus vital to the individual’s hospitalisation. Simultaneously, it adds to the nursing mandate by addressing inequality in health. Hence, social nursing functions at two level; an individual level where a holistic approach contributes to diminishing marginalisation of the patient; and a community level where the nursing mandate contributes towards reducing inequality in health and marginalisation during hospitalisation.

In a future development of social nursing, it will be important to study how social nursing is managed in a hospital setting.

The social nursing approach encompasses experience and evidence-based knowledge; knowledge about how to orchestrate efforts to reduce patients’ vulnerability and always with a holistic approach, trying to see and understand patients as whole persons; an experience working with the system to avoid losing the patients and thus assuring successful treatment.

The study shows that the social nurse helps the healthcare professionals navigate in the patient’s world and vice versa; and that this navigation task is particularly difficult for the system. It is vital to adapt and develop the healthcare system, which harbours the main challenges in relation to ensuring successful treatment. The social nurse is instrumental to furthering this end by creating the frame within which the healthcare professionals and the patient can meet in mutual understanding, which increases the probability of treatment adherence and success.

The study concludes that the social nurse works according to a holistically based nursing perspective essential for solving all tasks and fundamental to the general approach to both socially marginalised patients and the hospital system. Doing so, the social nurse draws upon the nursing mandate and contributes to the effort to reduce inequality in health and marginalisation during hospitalisation.

Applying the social nursing approach as a general approach allows optimised treatment that fosters a more equal outcome across the spectrum of socially marginalised patients. Hence, the social nursing approach may contribute to diminishing health inequalities. However, this needs to be further examined in future research.