NURSING PHD STUDENT TEASES APART THE COMPLICATED HISTORY OF ONE OF NURSING’S MOST WIDELY TAUGHT SKILLS
PhD Graduate Dr. Cory Ellen Gatrall demystified the origins of cultural competence and its implications on patients.
Dr. Cory Ellen Gatrall is part of the newest cohort of graduates at UMass Amherst earning her Ph.D. in Nursing in May 2024. Gatrall is no stranger to UMass– she earned her BS in Nursing from the Commonwealth’s Flagship Campus in 2014. Additionally, she holds an AB in Anthropology from Vassar College and an MFA in Creative Writing from Sarah Lawrence College. Clearly, she isn’t afraid of earning her education.
At the beginning of nursing school, Gatrall learned the term cultural competence. In nursing, it’s defined as a set of skills which clinicians use to help make culturally-sensitive choices. On the surface, it sounds great; but as many nurses learn, it can have negative impacts on the health outcomes of patients. “When I started seeing this play out, I was horrified and mystified,” she recalled.
As it is commonly put into practice, cultural competence may encourage clinicians to make assumptions based on a patient’s “culture” to provide medical care. For example, a clinician might assume that a new mother wants to stop breastfeeding and start using instant formula because of her background. In doing so, the nurse fails to investigate the real reason: whether the patient made this choice because of pain, whether the patient doesn’t have time off from work, or whether the patient is concerned about producing enough milk. Gatrall stated, “these are all common early challenges while breastfeeding, but instead it’s simply chalked up to ‘culture.’”
At present, cultural competence can allow clinicians to glaze over the real reason for the patient’s decision. As a result, damaging stereotypes are propagated, and ultimately the patient is the one who suffers the consequences. Gatrall aimed her PhD thesis at figuring out the roots of cultural competence, with the aim of elucidating where it went wrong and how it might have gone differently. Reflecting on the tangled history of cultural competence, Gatrall highlighted, “you don’t know what you don’t know until you uncover it.”
Cultural competence wasn’t born from one, solid thing. Gatrall described it as “a mishmash of trajectories that came together at a very specific historical moment involving gender, rigor, and science.” Historically, nurses in the United States were trained in hospitals, but the training moved to universities in the 1950s and 60s. Nursing emerged in academia as a new field, but there were no Nursing PhDs to teach classes. Bedside nurses gained their degrees in other fields to teach, resulting in a new cohort of university-trained nurses. The majority of these individuals were white women with a fairly homogeneous identity.
Gatrall believes that historical research is a “strategic roadmap” to understand how some actions pose a threat to equity. Through her research on the history of cultural competence, Gatrall learned that the term is tightly associated with Madeleine Leininger, who was influential on bringing culture into nursing training starting in the 1960s. Gatrall couldn’t interview Leininger, who passed away in 2012, so she did the next best thing: she hopped on a plane and spent a week in Leininger’s archives at Florida Atlantic University. Gatrall described that she was “elbow-deep in boxes of Leininger’s papers.”
Gatrall read course notes, syllabi, and papers from Leininger’s time at graduate school– anything that offered insight into Leininger’s thinking. She even read a letter Leininger wrote to her brother describing why she was choosing nursing school over the seminary. As Gatrall states, “In order to do really good historical work, you need far more context than you are ever going to write about.”
By reading Leininger’s notes, Gatrall realized that Leininger called for different ways of supervising nurses. Leininger suggested additional supervision for what she referred to as “ethnic minority nurses” who needed support from “academically qualified” nurses when caring for patients of color. That’s when Gatrall started digging for other people involved in nursing education and racial disparities during this time period, which is when she found Dr. Marie Branch. Branch is a Black nurse who earned her doctorate in Chiropractics, taught nursing at UCLA, and co-founded the Black Panther Party’s Free Clinic in Los Angeles. Dr. Branch was Gatrall’s next best hope at learning the tangled history of cultural competence.
Gatrall reached out to Branch’s daughter, and to her satisfaction, she answered. At the time, Branch had just turned 92 years old. Gatrall flew out to California to meet Branch, which Gatrall described as “wonderful” experience, and returned with stacks and stacks of Branch's early correspondence. Branch’s work predated the core concepts of cultural competence, instead promoting a value that many medical practitioners strive for today: antiracist care. Although Branch tried to infuse antiracist principles into academic nursing, it was an uphill battle that her primarily white colleagues often resisted.
“The throughline of my work is health equity, whether I’m working in reproductive justice or with abortion doulas... what I care about is blowing up barriers in health access and health equity.”
Gatrall highlights the function of white supremacy to suppress knowledge production by Black and brown scholars, which ultimately narrows the field of possibility for theory and practice and allows ideas like cultural competence to gain traction. Her research emphasizes why we must learn our history not only to recognize when a problematic idea is gaining traction, but also to identify the problematic ideas that are already part of the social norm.
Gatrall described her work as uncovering and revealing how racism, whiteness, and systems of oppression squash the thoughts of people who are pushed to the side. Through research of records from Madeleine Leininger and Dr. Marie Branch, Gatrall parsed apart how new, mostly white, nurses in a new scholarly field were trained. Gatrall said that “outrage is a renewable resource” for her and continues to uncover reasons why cultural competence is the norm for practicing nurses, like herself, today.
Currently, Gatrall is a Postdoctoral Fellow with the Abortion Care Training Incubator for Outstanding Nurse Scholars (ACTIONS) at the University of California San Francisco. In addition to her research, she is a Labor and Delivery nurse and serves as the co-leader of Doula Association for Reproductive Loss and Abortion (DARLA). She describes the role of a doula as providing “wrap around support” for the patient. Gatrall emphasized, “The throughline of my work is health equity, whether I’m working in reproductive justice or with abortion doulas... what I care about is blowing up barriers in health access and health equity.”
Gatrall has earned many fellowships and awards including Research Associate, Five College Women’s Studies Research Center, Project Title: Beyond the Pale: Race, Culture & Whiteness in the Discipline of Nursing (2024–25); PhD Excellence in Research Award, Elaine Marieb College of Nursing, UMass Amherst (2024); and Class of 1959: Faculty of the Future Award, Elaine Marieb College of Nursing (2021).
Written by Sarah Mirza, PhD student in Animal Biotechnology and Biomedical Sciences, as part of the Graduate School's Public Writing Fellows Program.