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Nurs Outlook 63 (2015) 488e495
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Holistic review in admissions: A strategy to diversify the nursing workforce Linda D. Scott, PhD, RN, NEA-BC, FAANa,*, Julie Zerwic, PhD, RN, FAHA, FAANb a
b
Department of Health Systems Science, University of Illinois at Chicago College of Nursing, Chicago, IL Department of Biobehavioral Health Science, University of Illinois at Chicago College of Nursing, Chicago, IL
article info
abstract
Article history: Received 9 September 2014 Revised 28 December 2014 Accepted 5 January 2015 Available online 13 January 2015
Individuals both within and outside the nursing profession have called for more diversity in nursing, from the education arena to the workforce. Implementing initiatives that address diversity and determining their effects have been limited. The University of Illinois at Chicago College of Nursing used the American Association of Medical Colleges Holistic Review Project as a platform to implement a process and paradigm shift for admissions to its nursing programs. We believe that the use of holistic admissions can increase the diversity among nursing students and provide the first step toward a diversified nursing profession. In hopes of assisting other institutions, we describe our experiences with preparing and implementing a holistic admissions process within the context of lessons learned and continued challenges. Furthermore, we hope our efforts will serve as a catalyst for a national dialogue on the use of holistic review as a strategy for the development of a more diverse nursing workforce.
Keywords: Cultural diversity School admission criteria Nursing education
Cite this article: Scott, L. D., & Zerwic, J. (2015, AUGUST). Holistic review in admissions: A strategy to diversify the nursing workforce. Nursing Outlook, 63(4), 488-495. http://dx.doi.org/10.1016/ j.outlook.2015.01.001.
There is a critical need for more diversity in nursing, from the education arena to the workforce. Although racial and ethnic minorities are predicted to comprise more than half of the U.S. population in the next 20 years, this predominance is not reflected in the ranks of nursing education or practice. Likewise, of the 3.1 million registered nurses (RNs) in the United States, only 16.6% are from underrepresented groups (U.S. Department of Health and Human Services Health Resources and Services Administration, 2010). In particular, the historically underrepresented groups of Black/African American and Hispanic nurses remain troublingly low. African Americans are 12.2% of the U.S. population yet only 5.4% of the nursing workforce; Hispanics are 15.4% of the U.S.
population but only 3.6% of the nursing workforce (U.S. Department of Health and Human Services Health Resources and Services Administration, 2010). Although the representation of men as RNs has increased since 2008, men still comprise only 9.6% of the American nursing workforce (U.S. Census Bureau, 2013), making them an additional underrepresented population in nursing. It has also been well documented that the lack of a diverse workforce jeopardizes the health of the nation (Brooks-Carthon, Kutney-Lee, Sloane, Cimiotti, & Aiken, 2011; Institute of Medicine, 2003). Nationally, ethnic and racial minorities and other marginalized groups experience significant health disparities as evidenced by lower quality of care, disproportionate
* Corresponding author: Linda D. Scott, University of Illinois at Chicago College of Nursing, 845 S. Damen Avenue (MC 802), Chicago, IL 60612. E-mail address: [email protected] (L.D. Scott). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.01.001
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health care services, and higher mortality rates. For example, The death rate for Blacks/African Americans is higher than whites for heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS (U.S. Department of Health and Human Services Office of Minority Health, 2013a). The mortality rate for Black/African American infants is 2.3 times the infant mortality rate of nonHispanic whites. Black/African Americans are three times as likely to die as infants because of complications related to low birth weight compared with non-Hispanic whites (U.S. Department of Health and Human Services Office of Minority Health, 2013b). Hispanics and Black/African American youth are more likely to die from diabetes than their nonHispanic white counterparts (Lipton, Good, Mikhailov, Freels, & Donoghue, 1999). Lesbian, gay, bisexual, and transgendered youth are more likely to attempt suicide (Garofalo, Wolf, & Wissow, 1999; Mustanski & Liu, 2013). Lesbians are less likely to seek preventive cancer care (Bureau of Labor Statistics, 2012; Dilley, Simmons, & Boysun, 2010). It is predicted that between 2000 and 2043, racial and ethnic minority groups will exceed 50% of the American population (U.S. Census Bureau, 2012). Disparities in health outcomes are expected to escalate as these populations increase in number and lack of access to health care providers persist in general (National Association of Community Health Centers, 2007), especially access to health care providers who resemble the populations in need of care (U.S. Department of Health and Human Services, 2011). Given these statistics, a diverse nursing workforce is critical. In addition, there is a need to have a nursing workforce that is representative of the populations it serves. It has been noted that minority health care providers are more likely to practice among underserved populations in a culturally appropriate and sensitive manner and within their own communities (Health Resources and Services Administration Bureau of Health Professions, 2006; The Sullivan Commission, 2004). As such, admission to nursing education programs must be designed to result in a student body that represents all areas of diversity and inclusion of individuals that are often marginalized, such as those from low socioeconomic and sexual minority populations and those with disabilities. Although other health professions have taken active steps to address this issue, initiatives that address diversity and determining their effects in nursing have been limited. This is particularly true for the concept of holistic review and its impact on the diversity of students within health professions’ educational programs. For example, the Urban Serving Universities (2014) recently conducted a survey of health science colleges. Of the 228 programs that
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responded, 29% were bachelor of science in nursing programs. Only 48% of health science programs reported using some elements of holistic review (Urban Universities for Health, 2014). However, the investigators did not report the results for the individual professional programs. The University of Illinois at Chicago (UIC) College of Nursing (CON) used the American Association of Medical Colleges (AAMC) Holistic Review Project as a platform to implement a process and paradigm shift for admissions to its undergraduate and graduate nursing programs. We chose to work with the AAMC because professional nursing organizations do not have published guidelines for holistic review. The purpose of this article is to describe the process and the components that we believe are integral to meeting diversity and inclusivity goals in nursing and to present lessons learned from its implementation.
Holistic Review Description and Rationale Holistic review is also referred to as comprehensive or individualized review. The AAMC describes holistic review as “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and future physician” (Addams, Bletzinger, Sondheimer, White, & Johnson, 2010, p. 10). Holistic review is a process of considering applicants using data from a variety of sources to determine the attributes that individuals will bring to the profession. The emphasis shifts from determining how successful an applicant will be as a student to the contribution that the applicant will make to the profession. The diversity of the class is monitored, and candidates are considered in the context of the diversity of the entire class. There are important reasons why holistic review is implemented. The first is the recognition that measures such as grade point averages (GPAs) or scores on standardized tests only reflect one aspect of an individual’s qualifications for admission. Equally important may be an applicant’s ability to speak another language, time spent volunteering in another country, time spent serving in the military, or having a disability. A second reason to implement holistic review is to create a teaching/learning environment that fosters different values, beliefs, and views of the world, laying the foundation for a more robust and productive experience for all participants. The AAMC suggests using the framework of experience, attributes, and academic metrics for evaluating applicants in a manner that is aligned with the program’s mission and goals (Addams et al., 2010). Experience includes the path that individuals have taken to
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get to their current point, such as education and employment, as well as life opportunities and challenges. Attributes are one’s personal and professional characteristics, coupled with skills and abilities possessed at the time of application. Academic metrics are the objective and quantifiable aspects of a student’s application (i.e., GPA, achievement tests, and graduate record examination). Identifying a balance of experiences, attributes, and academic metrics among individual applicants, as well as the class as a whole, with intentional, purposeful effort puts the institution in a better position to achieve its mission and goals (Addams et al., 2010). Moreover, it provides a mechanism to create and sustain an environment in which all students can succeed as students and health care professionals (AAMC, 2013). An educational environment that values diversity and inclusivity is more likely to prepare graduates to practice among underserved populations and understand their cultural needs while improving patient satisfaction and trust (Urban Universities for Health, 2014). Despite these advantages, faculty tend to believe that the only way to identify the “best and brightest” applicants is to use GPA or other test scores, fostering an overreliance on academic metrics. Frequently, undergraduate GPAs and achievement tests are used to prescreen applicants and weigh heavily in admission decisions. A recent study of medical school admissions found that undergraduate GPAs and Medical College Admission Test (MCAT) scores were believed to be the most important factors used to determine who should be interviewed and selected for admission, especially because the number of applicants increased over the years (Monroe, Quinn, Samuelson, Dunleavy, & Dowd, 2013). However, other studies have found limitations in the ability of MCAT scores to predict student performance and success (Donnon, Paolucci, & Violato, 2007; Julian, 2005). Applicants with lower standardized scores who possess a strong record of other forms of achievements have been found to be competitive and successful in their academic pursuits (Mattson, 2007; National Center for Fair and Open Testing, 1998; Sackett, Kuncel, Waters, Cooper, & Arneson, 2009). It is also important to recognize that heavy reliance on standardized testing creates a barrier for underrepresented students who may otherwise be highly qualified for admission and academic success. Another common perceived barrier to the use of holistic review in the admissions processes is the concern about legal ramifications. Under federal law, higher education institutions must give serious, good faith consideration to race-neutral alternatives that will assist in the achievement of their diversity goals (Coleman, Palmer, Winnick, Holland, & Knight, 2008; Steinecke, Beaudreau, Bletzinger, & Terrell, 2007). Because holistic review examines all aspects of an individual’s ability to contribute to a diverse educational environment and involves all races without automatic selection, it serves as a mechanism by which diversity goals can be achieved (Coleman et al., 2008).
Implementation of Holistic Review in Nursing Admissions In our efforts to achieve our goal to have a diverse student body, the UIC CON shifted to a holistic admission process. We describe experiences, opportunities, and challenges encountered along the way. We also provide recommendations for consideration as well as questions to explore with this endeavor.
Preparation for a Paradigm Shift Determining the foundation that an institution has for engaging in diversity planning is critical for the success of the holistic admission process. Reviewing the institution’s mission, vision, and goals will help identify the commitment and strategic direction for diversity. Before the UIC CON implemented holistic admissions, the campus engaged in a diversity strategic analysis across campus units (UIC, 2012a, 2012b). These efforts culminated in unit-level diversity strategic plans. The CON developed goals and strategies that focused on recruitment, retention, and development of students, staff, and faculty. Around this same time, the faculty revised the mission of the CON to explicitly identify a focus on the preparation of leaders from diverse backgrounds. The UIC CON mission is to transform health, health care, and policy through knowledge generation and translation and to educate future leaders from diverse backgrounds.
Preparation for Implementing Holistic Admissions Implementing a holistic admissions process requires that faculty engage in crucial conversations about college goals as well as personal beliefs and values. It is important to determine whether this conversation should be facilitated by individuals internal or external to the college or university. At UIC, we decided that we needed outside facilitators who had experience in leading this type of dialogue as well as the ability to direct the process to achieve the desired goals at the end of a 1-day workshop. The AAMC had published a number of articles describing the holistic workshop that they implement for medical school training (Addams et al., 2010; AAMC, 2013, 2014). We entered into multiple conversations with the organization and determined that, together, we could modify the workshop materials (e.g. exercises and case studies) to focus on the challenges and individual characteristics relevant to nursing, rather than use those materials that are designed for medical faculty and admissions personnel. At this time, only one other nursing program had engaged the AAMC for formal training in holistic review.
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At the very beginning of the process, the college leadership committed resources to this endeavor. This included the faculty and staff time that would be involved, as well as the resources needed for the workshop (facilitators, meals/refreshments). All administrative leaders, regional directors, program directors, admission committee members, faculty, and staff who were to participate in upcoming admission decisions were required to attend the holistic review workshop. This requirement was a very important detail. Often, faculty and staff will choose not to participate in development activities because they do not feel the content is relevant to them personally. We believed that it was critical that all faculty and staff were trained using the same framework and had a common foundation for the work that they would be undertaking. Therefore, we were firm in our commitment to 100% participation. If faculty could not join us, they were not able to participate in the review and selection of applicants for the next admission cycle.
The Holistic Review Workshop The preparation for the actual workshop began with a self-assessment process that focused on current UIC CON admission practices and the development of examples and case studies that illustrated common challenges. Because much of the work occurred within small group discussions during the workshop, faculty and staff were randomly assigned to small groups. The major topics included the following: Exploring assumptions and recognizing the multiple dimensions of diversity Connecting diversity to the institutional mission Principles of the holistic admissions process (experiences, attributes, and academic metrics) Translating the mission to admissions criteria Shaping a diverse class It should be recognized that the content of the workshop and discussion may trigger emotional responses for some individuals who have experienced biases in the past that may require immediate debriefing or conversations at a later point.
Implementing Holistic Review in the Admission Process Training in holistic review provided an opportunity for faculty and staff to identify new or ongoing issues that should be addressed in the admissions process. However, it was emphasized that this may take multiple cycles of revision and analysis to determine whether the desired outcomes are achieved. In addition, faculty may choose to revise application materials and/or the process of review after holistic review training.
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At the UIC CON, the application had already been made available to prospective students so it could not be revised for its upcoming cycle. Instead, the undergraduate and graduate admission committees focused on revisions to the review and decision aspects of the process. Previously, graduate student applicants were screened, and then a selected number of applicants were interviewed, whereas undergraduate applicants were not interviewed. Based on the discussion at the workshop, the faculty and staff recognized the need to identify those characteristics that applicants bring that were not being revealed in the application materials. In the workshop, it was referred to as looking below the surface of the iceberg. It is possible that applications could be designed to capture more of these characteristics; however, faculty at the UIC CON were concerned that the current application did not provide enough information to fairly evaluate all applicants. Therefore, the admission committees decided that all applicants who met the minimum requirements would be interviewed. Group interviews were used with undergraduate applicants to reduce faculty burden, whereas the graduate admission committee decided to continue with individual interviews. Standard questions were used for all applicants. The questions were carefully selected to allow applicants to demonstrate their ability to communicate with the interviewers and (in the case of the undergraduates) their peers. The interviews provided information about the applicants’ engagement and interest, decision-making and problem solving abilities, resourcefulness and resilience, and understanding of the program to which they were applying. The committees decided to separate interview and application reviews, so that one faculty member would not be the sole individual rating an applicant’s experiences and attributes. The interviews and applications were scored, and short comments often were provided to justify the score. Interview questions were drafted for all degree programs to provide more insight into an applicant’s attributes and experiences as well as consistency among interviewers. Table 1 provides examples of interview questions. This information and GPAs were considered as a whole as admission decisions were made. An overall score was not created; rather, individuals were selected based on their individual strengths. The following examples (pseudonyms used) show the different experiences and attributes of three applicants to the BSN program: Kathy Smith is a 20-year old who immigrated to the United States from Poland when she was 10. She has completed 2 years at UIC; her undergraduate GPA is 3.2, and her science GPA is 3.1. She is fluent in Spanish and Polish. She has extensive volunteer service activities, including a summer volunteering in Mexico. Reference letters are very strong and laud her interpersonal skills and her eagerness to learn. Faculty who interviewed her rated her very high.
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Table 1 e Examples of Interview Questions Interview Questions for BSN Applicants 1. What excites you most about nursing and why? 2. What do you see as the most important issue in healthcare? 3. Which previous learning experience did you find the most meaningful, and how would you apply it to nursing? 4. Where do you see yourself, professionally, in 5 years?
Interview Questions for DNP Applicants 1. Please tell me about your decision to pursue DNP education. 2. Please tell me about your understanding of the role of your chosen specialty and what makes you a good fit for this specialty? 3. How do you envision your life as a graduate student, and what plans to you have to integrate home, work, and school life? 4. Can you tell me about an experience in which diversity played a major role? This may reflect racial or ethnic diversity, diversity of thought, or cultural diversity. 5. If admitted, what will you bring to your class, the College of Nursing and the profession of advanced practice nursing? 6. Is there anything you would like to comment on regarding your written application?
BSN, bachelor of science in nursing; DNP, doctor of nursing practice.
Michael Johnson is a 28-year-old Black man. He is transferring from a community college with an overall GPA of 3.04 and a science GPA of 4.0. He struggled in his first year of college and was forced to drop out after financial issues. His essays described an ethical situation that he struggled with and was able to overcome. He does not have any experience with health care, but in his small rural community he was part of the volunteer fire department. Faculty during the interview saw a high level of maturity and interpersonal skills.
necessary for students’ success. For example, if veterans are admitted, it is important to have in place resources in the college or on campus to ensure their success. Is there a veterans’ center that works with students for issues such as financial aid, counseling, and academic skills? Perhaps students for whom English is a second language will need access to writing resources. This is also a change for faculty, and it is important to determine what resources and training are needed to assist faculty in their work with students who come from backgrounds that are unlike their own. The faculty need
Susan Waller is a 40-year-old non-Hispanic white woman. Her overall GPA from UIC is 3.3, and her science GPA is 3.0. She has four children between the ages of 6 and 18. She has worked for the last 15 years in a nonprofit organization that provides social services for an underserved community on the South Side of Chicago. Her reference letters praise her commitment to underserved populations. Her interviewers commented on her skills interacting with other applicants. These three applicants would not have been admitted if we had continued to weigh academic metrics as the predominant factor in the admissions decision. Although they all met the minimum requirements, their GPA would not have been high enough to make their applications competitive. However, because the admission committee shifted their focus to consider the experiences and attributes of these applicants, their future value to the nursing profession could be identified (Figure 1).
Continuing Challenges The admission of a diverse class is only the first step. The faculty will need to determine what resources are
Figure 1 e Application of the ExperiencesAttributes-Metrics Model to Nursing.
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to examine the curriculum to determine whether the courses address aspects of diversity that are now represented by the students in their classes. For example, in health assessment, content related to sexual minorities and the challenges associated with providing compassionate care to transgender individuals should be included. Students will quickly identify whether the commitment to diversity is genuine. Faculty who are involved in admissions will change, and new faculty and staff will join the CON. It will be necessary to determine what type of training is needed to continue to educate faculty in the holistic review process. It is resource intensive to conduct daylong holistic review workshops every year, so it will be important to determine foundational concepts that can be provided to new faculty and staff. It is also important to determine what conversations need to take place each year to maintain a commitment to holistic review. To continue the process at the UIC, faculty on the undergraduate and graduate admissions committee decided to use a “train-the-trainer” model to develop 2-hour workshops for new faculty and staff to learn about holistic review for upcoming admission cycles. Faculty recognized that they were struggling with the concept of admitting students based on an overall class diversity because they review and make recommendations about individual candidates. It is important to determine at what point in the process the composition of the entire class should be considered as well as how that should be determined. Admissions is a labor-intensive process, and it is important to identify the costs and benefits of each phase of the process. At the UIC CON, we added an interview for the undergraduate applicants. Although two faculty interviewed a group of students, completed in 30-minute blocks, this did add faculty and staff time to the process. An unexpected benefit was that applicants indicated that they appreciated the opportunity to come to the college (Skype, a division of Microsoft; Luxembourg, Western Europe was used for those who could not be present; e.g., out-of-state applicants). Staff perceived that this personal interaction contributed to an increased yield for accepted students who were also considering other programs, especially among applicants desiring to pursue graduate studies.
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matriculated students, graduates, faculty, and institutional characteristics (AAMC, 2013). Although racial/ethnic background is only one characteristic of diversity, it is a measure that we have tracked carefully over the years. At the UIC, no race or ethnicity is in the majority for the undergraduate student body although in nursing we have had a nonHispanic White majority. In 2013, the non-White categories for matriculated nursing students were 36.8%, with an increase to 42.5% in 2014. At the baccalaureate level, we experienced a significant increase in the number of underrepresented students who were offered and accepted admission to our program with 40 of the 81 African American and Hispanic students (49%) enrolling in the fall 2014 BSN cohort. For accepted graduate students, 21% were from underrepresented minority populations. As a result, 25% of incoming master’s students, 17% of Doctor of Nursing Practice students, and 41% of PhD students are URMs. Gender remained relatively stable at 10.6% in 2013 and 11.0% in 2014. The impact of holistic review on faculty should also be a component of the evaluation plan. Faculty members involved in the workshop and admission process were surveyed after all admissions were completed. The goal was to identify their opinions about the workshop, beliefs about what worked, and continuing issues with the admissions process. There was a range of opinions received, from those who saw little value in the workshop and thought the changes made were too labor-intensive to those who embraced the shift in practice and thinking. The following comments about the workshop reflect the themes noted: “I think we should be thinking about diversity in many ways. For example, a student who grew up in a family with mental illness or homelessness brings needed diversity to nursing that goes beyond racial/ ethnic categories. I also think that a Native American candidate who has interests within the Native American community should be evaluated differently than one who has no interest in an underrepresented community. I think we have started to scratch the surface, but it’s important to get to the next level.” “Learning that my first impressions may bias my opinion of the applicant.”
Evaluation It is important to evaluate both the direct and indirect outcomes of holistic review. The goals of the evaluation should include whether holistic review was successful in supporting the mission and vision of the institution as well as the impact of diversity on the learning environment for students. An evaluation plan should be developed to include process and outcome characteristics that are focused on applicants,
“Some of it was very tedious to me. I feel I recognize diversity and students with special issues.” The survey as well as interactions with faculty indicated that not all faculty found value in the workshop or the need to make any changes in the application process. Although we recognize that 1 day of training did not produce a shift for each individual, we believe that, as a collective, enough faculty were committed to this approach to shift the CON’s process toward holistic review admissions.
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Maintaining that momentum will be an important challenge for the CON. We are in the process of developing a comprehensive evaluation plan that will examine the impact of the holistic process from all perspectives.
Conclusion In summary, for holistic review to be actualized in a nursing college, it is necessary to take a frank look at the current culture and preparedness for paradigm shift. We recognized that it would require a disciplined and long-term institutional commitment. We required all faculty participating in admissions to attend a workshop related to holistic review. The admissions committees changed aspects of the review process to ensure a holistic approach. Holistic review in our college resulted in the first step to enhance the diversity of our students. The nursing profession still faces challenges in producing a workforce that mirrors the population it serves. This factor has contributed to the continuing health disparities for historically underrepresented and marginalized populations and communities. Although isolated discussions have focused on these issues, the nursing profession has not initiated a national dialogue to address barriers and solutions to diversifying the nursing workforce. We believe that holistic review admissions can address diversity among nursing students and provide the first step toward achieving diversity in the nursing profession.
Acknowledgments The authors thank Kevin Grandfield, Publication Manager of the UIC Department of Biobehavioral Health Science, for editorial assistance.
references
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www.nursingoutlook.org
Holistic review in admissions: A strategy to diversify the nursing workforce Linda D. Scott, PhD, RN, NEA-BC, FAANa,*, Julie Zerwic, PhD, RN, FAHA, FAANb a
b
Department of Health Systems Science, University of Illinois at Chicago College of Nursing, Chicago, IL Department of Biobehavioral Health Science, University of Illinois at Chicago College of Nursing, Chicago, IL
article info
abstract
Article history: Received 9 September 2014 Revised 28 December 2014 Accepted 5 January 2015 Available online 13 January 2015
Individuals both within and outside the nursing profession have called for more diversity in nursing, from the education arena to the workforce. Implementing initiatives that address diversity and determining their effects have been limited. The University of Illinois at Chicago College of Nursing used the American Association of Medical Colleges Holistic Review Project as a platform to implement a process and paradigm shift for admissions to its nursing programs. We believe that the use of holistic admissions can increase the diversity among nursing students and provide the first step toward a diversified nursing profession. In hopes of assisting other institutions, we describe our experiences with preparing and implementing a holistic admissions process within the context of lessons learned and continued challenges. Furthermore, we hope our efforts will serve as a catalyst for a national dialogue on the use of holistic review as a strategy for the development of a more diverse nursing workforce.
Keywords: Cultural diversity School admission criteria Nursing education
Cite this article: Scott, L. D., & Zerwic, J. (2015, AUGUST). Holistic review in admissions: A strategy to diversify the nursing workforce. Nursing Outlook, 63(4), 488-495. http://dx.doi.org/10.1016/ j.outlook.2015.01.001.
There is a critical need for more diversity in nursing, from the education arena to the workforce. Although racial and ethnic minorities are predicted to comprise more than half of the U.S. population in the next 20 years, this predominance is not reflected in the ranks of nursing education or practice. Likewise, of the 3.1 million registered nurses (RNs) in the United States, only 16.6% are from underrepresented groups (U.S. Department of Health and Human Services Health Resources and Services Administration, 2010). In particular, the historically underrepresented groups of Black/African American and Hispanic nurses remain troublingly low. African Americans are 12.2% of the U.S. population yet only 5.4% of the nursing workforce; Hispanics are 15.4% of the U.S.
population but only 3.6% of the nursing workforce (U.S. Department of Health and Human Services Health Resources and Services Administration, 2010). Although the representation of men as RNs has increased since 2008, men still comprise only 9.6% of the American nursing workforce (U.S. Census Bureau, 2013), making them an additional underrepresented population in nursing. It has also been well documented that the lack of a diverse workforce jeopardizes the health of the nation (Brooks-Carthon, Kutney-Lee, Sloane, Cimiotti, & Aiken, 2011; Institute of Medicine, 2003). Nationally, ethnic and racial minorities and other marginalized groups experience significant health disparities as evidenced by lower quality of care, disproportionate
* Corresponding author: Linda D. Scott, University of Illinois at Chicago College of Nursing, 845 S. Damen Avenue (MC 802), Chicago, IL 60612. E-mail address: [email protected] (L.D. Scott). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.01.001
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health care services, and higher mortality rates. For example, The death rate for Blacks/African Americans is higher than whites for heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS (U.S. Department of Health and Human Services Office of Minority Health, 2013a). The mortality rate for Black/African American infants is 2.3 times the infant mortality rate of nonHispanic whites. Black/African Americans are three times as likely to die as infants because of complications related to low birth weight compared with non-Hispanic whites (U.S. Department of Health and Human Services Office of Minority Health, 2013b). Hispanics and Black/African American youth are more likely to die from diabetes than their nonHispanic white counterparts (Lipton, Good, Mikhailov, Freels, & Donoghue, 1999). Lesbian, gay, bisexual, and transgendered youth are more likely to attempt suicide (Garofalo, Wolf, & Wissow, 1999; Mustanski & Liu, 2013). Lesbians are less likely to seek preventive cancer care (Bureau of Labor Statistics, 2012; Dilley, Simmons, & Boysun, 2010). It is predicted that between 2000 and 2043, racial and ethnic minority groups will exceed 50% of the American population (U.S. Census Bureau, 2012). Disparities in health outcomes are expected to escalate as these populations increase in number and lack of access to health care providers persist in general (National Association of Community Health Centers, 2007), especially access to health care providers who resemble the populations in need of care (U.S. Department of Health and Human Services, 2011). Given these statistics, a diverse nursing workforce is critical. In addition, there is a need to have a nursing workforce that is representative of the populations it serves. It has been noted that minority health care providers are more likely to practice among underserved populations in a culturally appropriate and sensitive manner and within their own communities (Health Resources and Services Administration Bureau of Health Professions, 2006; The Sullivan Commission, 2004). As such, admission to nursing education programs must be designed to result in a student body that represents all areas of diversity and inclusion of individuals that are often marginalized, such as those from low socioeconomic and sexual minority populations and those with disabilities. Although other health professions have taken active steps to address this issue, initiatives that address diversity and determining their effects in nursing have been limited. This is particularly true for the concept of holistic review and its impact on the diversity of students within health professions’ educational programs. For example, the Urban Serving Universities (2014) recently conducted a survey of health science colleges. Of the 228 programs that
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responded, 29% were bachelor of science in nursing programs. Only 48% of health science programs reported using some elements of holistic review (Urban Universities for Health, 2014). However, the investigators did not report the results for the individual professional programs. The University of Illinois at Chicago (UIC) College of Nursing (CON) used the American Association of Medical Colleges (AAMC) Holistic Review Project as a platform to implement a process and paradigm shift for admissions to its undergraduate and graduate nursing programs. We chose to work with the AAMC because professional nursing organizations do not have published guidelines for holistic review. The purpose of this article is to describe the process and the components that we believe are integral to meeting diversity and inclusivity goals in nursing and to present lessons learned from its implementation.
Holistic Review Description and Rationale Holistic review is also referred to as comprehensive or individualized review. The AAMC describes holistic review as “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and future physician” (Addams, Bletzinger, Sondheimer, White, & Johnson, 2010, p. 10). Holistic review is a process of considering applicants using data from a variety of sources to determine the attributes that individuals will bring to the profession. The emphasis shifts from determining how successful an applicant will be as a student to the contribution that the applicant will make to the profession. The diversity of the class is monitored, and candidates are considered in the context of the diversity of the entire class. There are important reasons why holistic review is implemented. The first is the recognition that measures such as grade point averages (GPAs) or scores on standardized tests only reflect one aspect of an individual’s qualifications for admission. Equally important may be an applicant’s ability to speak another language, time spent volunteering in another country, time spent serving in the military, or having a disability. A second reason to implement holistic review is to create a teaching/learning environment that fosters different values, beliefs, and views of the world, laying the foundation for a more robust and productive experience for all participants. The AAMC suggests using the framework of experience, attributes, and academic metrics for evaluating applicants in a manner that is aligned with the program’s mission and goals (Addams et al., 2010). Experience includes the path that individuals have taken to
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get to their current point, such as education and employment, as well as life opportunities and challenges. Attributes are one’s personal and professional characteristics, coupled with skills and abilities possessed at the time of application. Academic metrics are the objective and quantifiable aspects of a student’s application (i.e., GPA, achievement tests, and graduate record examination). Identifying a balance of experiences, attributes, and academic metrics among individual applicants, as well as the class as a whole, with intentional, purposeful effort puts the institution in a better position to achieve its mission and goals (Addams et al., 2010). Moreover, it provides a mechanism to create and sustain an environment in which all students can succeed as students and health care professionals (AAMC, 2013). An educational environment that values diversity and inclusivity is more likely to prepare graduates to practice among underserved populations and understand their cultural needs while improving patient satisfaction and trust (Urban Universities for Health, 2014). Despite these advantages, faculty tend to believe that the only way to identify the “best and brightest” applicants is to use GPA or other test scores, fostering an overreliance on academic metrics. Frequently, undergraduate GPAs and achievement tests are used to prescreen applicants and weigh heavily in admission decisions. A recent study of medical school admissions found that undergraduate GPAs and Medical College Admission Test (MCAT) scores were believed to be the most important factors used to determine who should be interviewed and selected for admission, especially because the number of applicants increased over the years (Monroe, Quinn, Samuelson, Dunleavy, & Dowd, 2013). However, other studies have found limitations in the ability of MCAT scores to predict student performance and success (Donnon, Paolucci, & Violato, 2007; Julian, 2005). Applicants with lower standardized scores who possess a strong record of other forms of achievements have been found to be competitive and successful in their academic pursuits (Mattson, 2007; National Center for Fair and Open Testing, 1998; Sackett, Kuncel, Waters, Cooper, & Arneson, 2009). It is also important to recognize that heavy reliance on standardized testing creates a barrier for underrepresented students who may otherwise be highly qualified for admission and academic success. Another common perceived barrier to the use of holistic review in the admissions processes is the concern about legal ramifications. Under federal law, higher education institutions must give serious, good faith consideration to race-neutral alternatives that will assist in the achievement of their diversity goals (Coleman, Palmer, Winnick, Holland, & Knight, 2008; Steinecke, Beaudreau, Bletzinger, & Terrell, 2007). Because holistic review examines all aspects of an individual’s ability to contribute to a diverse educational environment and involves all races without automatic selection, it serves as a mechanism by which diversity goals can be achieved (Coleman et al., 2008).
Implementation of Holistic Review in Nursing Admissions In our efforts to achieve our goal to have a diverse student body, the UIC CON shifted to a holistic admission process. We describe experiences, opportunities, and challenges encountered along the way. We also provide recommendations for consideration as well as questions to explore with this endeavor.
Preparation for a Paradigm Shift Determining the foundation that an institution has for engaging in diversity planning is critical for the success of the holistic admission process. Reviewing the institution’s mission, vision, and goals will help identify the commitment and strategic direction for diversity. Before the UIC CON implemented holistic admissions, the campus engaged in a diversity strategic analysis across campus units (UIC, 2012a, 2012b). These efforts culminated in unit-level diversity strategic plans. The CON developed goals and strategies that focused on recruitment, retention, and development of students, staff, and faculty. Around this same time, the faculty revised the mission of the CON to explicitly identify a focus on the preparation of leaders from diverse backgrounds. The UIC CON mission is to transform health, health care, and policy through knowledge generation and translation and to educate future leaders from diverse backgrounds.
Preparation for Implementing Holistic Admissions Implementing a holistic admissions process requires that faculty engage in crucial conversations about college goals as well as personal beliefs and values. It is important to determine whether this conversation should be facilitated by individuals internal or external to the college or university. At UIC, we decided that we needed outside facilitators who had experience in leading this type of dialogue as well as the ability to direct the process to achieve the desired goals at the end of a 1-day workshop. The AAMC had published a number of articles describing the holistic workshop that they implement for medical school training (Addams et al., 2010; AAMC, 2013, 2014). We entered into multiple conversations with the organization and determined that, together, we could modify the workshop materials (e.g. exercises and case studies) to focus on the challenges and individual characteristics relevant to nursing, rather than use those materials that are designed for medical faculty and admissions personnel. At this time, only one other nursing program had engaged the AAMC for formal training in holistic review.
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At the very beginning of the process, the college leadership committed resources to this endeavor. This included the faculty and staff time that would be involved, as well as the resources needed for the workshop (facilitators, meals/refreshments). All administrative leaders, regional directors, program directors, admission committee members, faculty, and staff who were to participate in upcoming admission decisions were required to attend the holistic review workshop. This requirement was a very important detail. Often, faculty and staff will choose not to participate in development activities because they do not feel the content is relevant to them personally. We believed that it was critical that all faculty and staff were trained using the same framework and had a common foundation for the work that they would be undertaking. Therefore, we were firm in our commitment to 100% participation. If faculty could not join us, they were not able to participate in the review and selection of applicants for the next admission cycle.
The Holistic Review Workshop The preparation for the actual workshop began with a self-assessment process that focused on current UIC CON admission practices and the development of examples and case studies that illustrated common challenges. Because much of the work occurred within small group discussions during the workshop, faculty and staff were randomly assigned to small groups. The major topics included the following: Exploring assumptions and recognizing the multiple dimensions of diversity Connecting diversity to the institutional mission Principles of the holistic admissions process (experiences, attributes, and academic metrics) Translating the mission to admissions criteria Shaping a diverse class It should be recognized that the content of the workshop and discussion may trigger emotional responses for some individuals who have experienced biases in the past that may require immediate debriefing or conversations at a later point.
Implementing Holistic Review in the Admission Process Training in holistic review provided an opportunity for faculty and staff to identify new or ongoing issues that should be addressed in the admissions process. However, it was emphasized that this may take multiple cycles of revision and analysis to determine whether the desired outcomes are achieved. In addition, faculty may choose to revise application materials and/or the process of review after holistic review training.
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At the UIC CON, the application had already been made available to prospective students so it could not be revised for its upcoming cycle. Instead, the undergraduate and graduate admission committees focused on revisions to the review and decision aspects of the process. Previously, graduate student applicants were screened, and then a selected number of applicants were interviewed, whereas undergraduate applicants were not interviewed. Based on the discussion at the workshop, the faculty and staff recognized the need to identify those characteristics that applicants bring that were not being revealed in the application materials. In the workshop, it was referred to as looking below the surface of the iceberg. It is possible that applications could be designed to capture more of these characteristics; however, faculty at the UIC CON were concerned that the current application did not provide enough information to fairly evaluate all applicants. Therefore, the admission committees decided that all applicants who met the minimum requirements would be interviewed. Group interviews were used with undergraduate applicants to reduce faculty burden, whereas the graduate admission committee decided to continue with individual interviews. Standard questions were used for all applicants. The questions were carefully selected to allow applicants to demonstrate their ability to communicate with the interviewers and (in the case of the undergraduates) their peers. The interviews provided information about the applicants’ engagement and interest, decision-making and problem solving abilities, resourcefulness and resilience, and understanding of the program to which they were applying. The committees decided to separate interview and application reviews, so that one faculty member would not be the sole individual rating an applicant’s experiences and attributes. The interviews and applications were scored, and short comments often were provided to justify the score. Interview questions were drafted for all degree programs to provide more insight into an applicant’s attributes and experiences as well as consistency among interviewers. Table 1 provides examples of interview questions. This information and GPAs were considered as a whole as admission decisions were made. An overall score was not created; rather, individuals were selected based on their individual strengths. The following examples (pseudonyms used) show the different experiences and attributes of three applicants to the BSN program: Kathy Smith is a 20-year old who immigrated to the United States from Poland when she was 10. She has completed 2 years at UIC; her undergraduate GPA is 3.2, and her science GPA is 3.1. She is fluent in Spanish and Polish. She has extensive volunteer service activities, including a summer volunteering in Mexico. Reference letters are very strong and laud her interpersonal skills and her eagerness to learn. Faculty who interviewed her rated her very high.
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Table 1 e Examples of Interview Questions Interview Questions for BSN Applicants 1. What excites you most about nursing and why? 2. What do you see as the most important issue in healthcare? 3. Which previous learning experience did you find the most meaningful, and how would you apply it to nursing? 4. Where do you see yourself, professionally, in 5 years?
Interview Questions for DNP Applicants 1. Please tell me about your decision to pursue DNP education. 2. Please tell me about your understanding of the role of your chosen specialty and what makes you a good fit for this specialty? 3. How do you envision your life as a graduate student, and what plans to you have to integrate home, work, and school life? 4. Can you tell me about an experience in which diversity played a major role? This may reflect racial or ethnic diversity, diversity of thought, or cultural diversity. 5. If admitted, what will you bring to your class, the College of Nursing and the profession of advanced practice nursing? 6. Is there anything you would like to comment on regarding your written application?
BSN, bachelor of science in nursing; DNP, doctor of nursing practice.
Michael Johnson is a 28-year-old Black man. He is transferring from a community college with an overall GPA of 3.04 and a science GPA of 4.0. He struggled in his first year of college and was forced to drop out after financial issues. His essays described an ethical situation that he struggled with and was able to overcome. He does not have any experience with health care, but in his small rural community he was part of the volunteer fire department. Faculty during the interview saw a high level of maturity and interpersonal skills.
necessary for students’ success. For example, if veterans are admitted, it is important to have in place resources in the college or on campus to ensure their success. Is there a veterans’ center that works with students for issues such as financial aid, counseling, and academic skills? Perhaps students for whom English is a second language will need access to writing resources. This is also a change for faculty, and it is important to determine what resources and training are needed to assist faculty in their work with students who come from backgrounds that are unlike their own. The faculty need
Susan Waller is a 40-year-old non-Hispanic white woman. Her overall GPA from UIC is 3.3, and her science GPA is 3.0. She has four children between the ages of 6 and 18. She has worked for the last 15 years in a nonprofit organization that provides social services for an underserved community on the South Side of Chicago. Her reference letters praise her commitment to underserved populations. Her interviewers commented on her skills interacting with other applicants. These three applicants would not have been admitted if we had continued to weigh academic metrics as the predominant factor in the admissions decision. Although they all met the minimum requirements, their GPA would not have been high enough to make their applications competitive. However, because the admission committee shifted their focus to consider the experiences and attributes of these applicants, their future value to the nursing profession could be identified (Figure 1).
Continuing Challenges The admission of a diverse class is only the first step. The faculty will need to determine what resources are
Figure 1 e Application of the ExperiencesAttributes-Metrics Model to Nursing.
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to examine the curriculum to determine whether the courses address aspects of diversity that are now represented by the students in their classes. For example, in health assessment, content related to sexual minorities and the challenges associated with providing compassionate care to transgender individuals should be included. Students will quickly identify whether the commitment to diversity is genuine. Faculty who are involved in admissions will change, and new faculty and staff will join the CON. It will be necessary to determine what type of training is needed to continue to educate faculty in the holistic review process. It is resource intensive to conduct daylong holistic review workshops every year, so it will be important to determine foundational concepts that can be provided to new faculty and staff. It is also important to determine what conversations need to take place each year to maintain a commitment to holistic review. To continue the process at the UIC, faculty on the undergraduate and graduate admissions committee decided to use a “train-the-trainer” model to develop 2-hour workshops for new faculty and staff to learn about holistic review for upcoming admission cycles. Faculty recognized that they were struggling with the concept of admitting students based on an overall class diversity because they review and make recommendations about individual candidates. It is important to determine at what point in the process the composition of the entire class should be considered as well as how that should be determined. Admissions is a labor-intensive process, and it is important to identify the costs and benefits of each phase of the process. At the UIC CON, we added an interview for the undergraduate applicants. Although two faculty interviewed a group of students, completed in 30-minute blocks, this did add faculty and staff time to the process. An unexpected benefit was that applicants indicated that they appreciated the opportunity to come to the college (Skype, a division of Microsoft; Luxembourg, Western Europe was used for those who could not be present; e.g., out-of-state applicants). Staff perceived that this personal interaction contributed to an increased yield for accepted students who were also considering other programs, especially among applicants desiring to pursue graduate studies.
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matriculated students, graduates, faculty, and institutional characteristics (AAMC, 2013). Although racial/ethnic background is only one characteristic of diversity, it is a measure that we have tracked carefully over the years. At the UIC, no race or ethnicity is in the majority for the undergraduate student body although in nursing we have had a nonHispanic White majority. In 2013, the non-White categories for matriculated nursing students were 36.8%, with an increase to 42.5% in 2014. At the baccalaureate level, we experienced a significant increase in the number of underrepresented students who were offered and accepted admission to our program with 40 of the 81 African American and Hispanic students (49%) enrolling in the fall 2014 BSN cohort. For accepted graduate students, 21% were from underrepresented minority populations. As a result, 25% of incoming master’s students, 17% of Doctor of Nursing Practice students, and 41% of PhD students are URMs. Gender remained relatively stable at 10.6% in 2013 and 11.0% in 2014. The impact of holistic review on faculty should also be a component of the evaluation plan. Faculty members involved in the workshop and admission process were surveyed after all admissions were completed. The goal was to identify their opinions about the workshop, beliefs about what worked, and continuing issues with the admissions process. There was a range of opinions received, from those who saw little value in the workshop and thought the changes made were too labor-intensive to those who embraced the shift in practice and thinking. The following comments about the workshop reflect the themes noted: “I think we should be thinking about diversity in many ways. For example, a student who grew up in a family with mental illness or homelessness brings needed diversity to nursing that goes beyond racial/ ethnic categories. I also think that a Native American candidate who has interests within the Native American community should be evaluated differently than one who has no interest in an underrepresented community. I think we have started to scratch the surface, but it’s important to get to the next level.” “Learning that my first impressions may bias my opinion of the applicant.”
Evaluation It is important to evaluate both the direct and indirect outcomes of holistic review. The goals of the evaluation should include whether holistic review was successful in supporting the mission and vision of the institution as well as the impact of diversity on the learning environment for students. An evaluation plan should be developed to include process and outcome characteristics that are focused on applicants,
“Some of it was very tedious to me. I feel I recognize diversity and students with special issues.” The survey as well as interactions with faculty indicated that not all faculty found value in the workshop or the need to make any changes in the application process. Although we recognize that 1 day of training did not produce a shift for each individual, we believe that, as a collective, enough faculty were committed to this approach to shift the CON’s process toward holistic review admissions.
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Maintaining that momentum will be an important challenge for the CON. We are in the process of developing a comprehensive evaluation plan that will examine the impact of the holistic process from all perspectives.
Conclusion In summary, for holistic review to be actualized in a nursing college, it is necessary to take a frank look at the current culture and preparedness for paradigm shift. We recognized that it would require a disciplined and long-term institutional commitment. We required all faculty participating in admissions to attend a workshop related to holistic review. The admissions committees changed aspects of the review process to ensure a holistic approach. Holistic review in our college resulted in the first step to enhance the diversity of our students. The nursing profession still faces challenges in producing a workforce that mirrors the population it serves. This factor has contributed to the continuing health disparities for historically underrepresented and marginalized populations and communities. Although isolated discussions have focused on these issues, the nursing profession has not initiated a national dialogue to address barriers and solutions to diversifying the nursing workforce. We believe that holistic review admissions can address diversity among nursing students and provide the first step toward achieving diversity in the nursing profession.
Acknowledgments The authors thank Kevin Grandfield, Publication Manager of the UIC Department of Biobehavioral Health Science, for editorial assistance.
references
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