As we continue to move into the 21st century, we must strive to meet the challenging healthcare needs of our quickly diversifying population. Part of our solution will be the purposeful constructing of the healthcare workforce to benefit the chronically underserved demographic populations that have long been forgotten. African and Hispanic Americans are the fastest growing segments of the United States (U.S.) population; together with Native Americans they comprise nearly one-third of the national population (U.S. Census Bureau, 2013a). Currently, these groups are grossly underrepresented in the healthcare workforce, accounting for only 16.8% of nurses and 6% of practicing physicians (Association of American Medical Colleges [AAMC], 2006). This lack of diversity amongst healthcare workers has been shown to negatively affect patient outcomes (American Association of Colleges of Nursing [AACN], 2013; AAMC, 2006; U.S. Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Professions, 2006). The academic literature suggests that African and Hispanic American patients prefer to seek care from physicians of their own race, a luxury only European Americans have enjoyed historically (Saha, Taggart, Komaromy, & Bindman, 2000). It is projected that by 2050 our current minority populations will account for over half the national population. An increasingly diverse patient population needs a culturally diverse workforce that has the ability to provide high quality, culturally competent care (AACN, 2013; U.S. Census Bureau, 2013b).
The crafting of the future workforce is multiphasic. It needs to include the development of a rich pipeline of potential students upstream and a paradigmatic change in downstream processes, such as admissions processes for nursing programs, along with follow-up regarding how new nurses fare in the workplace. The phrase, ‘it takes a village,’ isn’t just a saying about raising our nation’s youth; it also holds true as nursing faculties and admissions committees pensively guide and select students entering the healthcare workforce. The workforce shouldn’t be a mere static assembly line of ‘qualified’ students entering nursing based on artificial metrics, such as grade point average (GPA) and Scholastic Aptitude Test (SAT) scores, which have been shown to be strongly correlated with parental attributes (Brown, Ortiz-Nuñez, & Taylor, 2012; Dahl & Lochner, 2008; Rothstein & Wozny, 2013).
The specific members of the healthcare workforce affect health outcomes and drive the quality of health for both the community and the nation at large. As such, the workforce needs to be carefully and thoughtfully crafted beginning with the pipeline of students entering universities and continuing throughout the nursing program’s admissions processes. Everyone in nursing, from administrators, to nurses in the field, to faculty and accrediting bodies, is responsible for cultivating a diverse workforce.
The purpose of this column is to briefly highlight issues in the current nursing workforce and advocate for the careful examination and adoption of a ‘holistic review’ admissions process by nursing schools. We need to diversity our workforce, and research shows that a promising way to do this is through a holistic review admissions process (Urban Universities for Health, 2014).
The admissions process, an important milestone in the process of shaping the workforce, functions as a gatekeeper as nursing schools recruit, select, and prepare potential nurses for professional practice. Holistic review is defined as a flexible, individualized way of assessing how an applicant will fare as a student and as a future professional and member of society (Urban Universities for Health, 2014). Holistic reviews exist on a continuum. Although universities and colleges can adopt varying practices of holistic review, it is important that selection criteria are broadly based and balanced. Under holistic review, admission committees consider a student’s life experiences and personal qualities alongside traditional measures of academic achievement, such as grades and test scores (Association of Medical Colleges, n.d.). While there have been concerns about how race and ethnicity may be considered during the admission process, in all but seven states (WA, MI, NE, AZ, NH, CA, FL) race and ethnicity may be considered as factors when making admission-related decisions, as long as the consideration is “narrowly tailored to achieve mission-related education and goals associated with diversity, and when considered as part of a broader mix of factors” (Urban Universities for Health, 2014, p. 3). In a recent study commissioned by Health Resources and Services Administration (HRSA) and the National Institutes of Health (NIH), researchers found that holistic admissions processes have been adopted by 93% of dentistry schools, 91% of medical schools, 82% of public health schools, 78% of pharmacy schools, and 47% of nursing schools (Urban Universities for Health, 2014).
Nursing has been slower to embrace holistic admissions practices, despite the growing body of evidence that supports the holistic admissions process. Nursing needs to transition to a broader, more balanced process that is not based solely on artificially crafted metrics. The change to a holistic review admissions process needs to be transparent and embraced at all levels of administration within universities, healthcare settings, and among professional associations and accrediting bodies.
Within universities, presidents, provosts, faculty admissions committees, and faculty themselves need to assess their current admissions practices and determine areas that could be modified to better assess the true attributes of the applicant. Faculties also need to develop a method for follow-up communication with healthcare settings to determine how well new graduates are prepared for their role as graduate nurses. This follow-up is important because the attributes that ensure success for the graduate nurse are yet to be clearly identified. Future research is needed to determine which incoming applicant attributes are correlated with success.
Stakeholders within healthcare institutions need to vocalize their needs to colleges and assist with developing the admissions criteria. For example, if multilingual nurses are needed, the school of nursing should give increased weight to dual-language skills during the admission process. The attributes requested by healthcare institutions should be reflected in the mission statement of the school/college.
Professional nursing associations need to fully embrace the transition to a holistic admissions process and provide training and data to assist nursing schools in using this process. When medical and dental schools began shifting to a more holistic process, the Association of American Medical Colleges and the American Dental Education Association began arming universities and stakeholders with data that supported the process (Urban Universities for Health, 2014).
Currently, the U.S. workforce is not representative of the populations we serve. Students having diverse backgrounds with rich life experiences are more inclined to have the background, perspective, and skills required to provide high quality care to their patients. Holistic review is not an agenda; it is not about race and ethnicity, but rather about improving learning environments and patient outcomes. The first step in transitioning to a more holistic approach is to take an honest look at one’s school/college’s current admissions practices to determine areas of improvement. The Holistic Review Scoring Model is a tool that can be used to assess schools’ use of holistic review practices. The Table below presents model practices identified by Holistic Admissions in the Health Professions National Survey Report.
Holistic admissions processes should be mission focused and individualized to each institution. Nursing has the prodigious responsibility of leading the change in healthcare. We cannot give quality care with a workforce that neglects the needs of nearly half of our patients.
Holistic Review Scoring Model from the report “Holistic Admission in the Health Professions: Findings from a National Survey” http://urbanuniversitiesforhealth.org/media/documents/Holistic_Admissions_in_the_Health_Professions.pdf). September, 2014. Reprinted with permission from Urban Universities for HEALTH.
Greer Glazer, PhD, RN, CNP, FAAN
Angela Clark, PhD, RN
Karen Bankston, PhD, RN, FACHE