- Email: [email protected]
Holistic admissions in undergraduate nursing: One school's journey and lessons learned
YJPNU-01080; No of Pages 6 Journal of Professional Nursing xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Professional Nursing
Holistic admissions in undergraduate nursing: One school's journey and lessons learned Peggy Wros a, Joanne Noone b,⁎ a b
Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Road, Portland, OR 97239, United States Oregon Health & Science University, School of Nursing, 1250 Siskiyou Boulevard, Ashland, OR 97520, United States
Background on nursing workforce diversity Improving the diversity of the nursing workforce is a key strategy for achieving culturally effective, patient-centered care and health equity (Smedley, Stith Butler, & Bristow, 2004). While the term “diversity” is generally interpreted broadly, data regarding minorities in the nursing workforce have been widely reported. Minority health care providers are more likely to work in underserved areas and provide care for minority populations (Goodfellow et al., 2016; Komaromy et al., 1996; Marrast et al., 2014). Minority patients are more likely to choose a healthcare provider of their own race or ethnicity because of personal preference and language concordance (Saha et al., 2000). It is encouraging that the numbers of minority nurses are increasing in the nursing workforce; however, the minority distribution of registered nurses (RNs) in the United States (U·S.) is not representative of the working population (U.S. Department of Health and Human Services, 2015). For example, black Americans constitute 13.6% of the workforce but only 10.7% of the registered nursing workforce. The disparity is even wider for registered nurses of Hispanic or Latino background with approximately 15.5% of the working population identified as Latino compared with 5.4% of registered nurses (U.S Department of Health and Human Services, 2015). Two recent analyses have identified a widening gap for minority nurses, in particular Hispanic nurses, as compared to the nursing workforce and the U.S. population growth. In a recent comparison of census data from 1980 to 2010, the U.S. Latino population tripled during those three decades, from 14.8 million to 50.7 million. During that same period, the Latino RN population grew by only a third from 213 Latino RNs per 100,000 Latinos in 1980 to 311 Latino RNs per 100,000 Latinos in 2010 (Hayes-Bautista, Schink, & Hayes-Bautista, 2016). Xue and Brewer (2014) analyzed data from the 1988 through 2013 from the National Sample Survey of Registered Nurses from 1988 to 2008 and the 2013 National Workforce Survey of Registered Nurses. The minority RN population grew from 7.7% to 18% during that time period while the U.S. minority population grew from 23.5% in 1988 to 37.3% in 2013. In comparing minority RN workforce to total population, there was a gap of 15.8% in 1988 that worsened to 19.3% in 2013. In an analysis of state data from the 2008 National Sample Survey of Registered Nurses, Oregon was identified as a state with a gap in Hispanic ⁎ Corresponding author. E-mail addresses: [email protected] (P. Wros), [email protected] (J. Noone).
representation in the nursing workforce as compared to the population (Xue & Brewer, 2014), with approximately 12% of the population in Oregon as Hispanic compared to 4% of the nursing workforce (Oregon Health Authority, 2014). Lack of diversity in the healthcare workforce has been identified by Oregon state health officials as a contributing factor to health inequity for Hispanic populations (Oregon Health Authority, 2013). Holistic admissions is a strategy currently being recommended by health professions education organizations to improve workforce diversity (American Association of Colleges of Nursing, 2016a; American Association of Medical Colleges, 2014). The purpose of this paper is to outline current recommended practices for implementation of a holistic admission process and describe one school of nursing's journey, including lessons learned, to implement holistic admissions in their undergraduate program. What is holistic admissions? Holistic admissions provides more equitable opportunities for educationally and economically disadvantaged students to enter nursing (Glazer, Clark, & Bankston, 2015) by considering an applicant's individual characteristics, background, and potential for contributing to the school and the profession in addition to more common academic criteria (American Association of Medical Colleges, 2014). The American Association of Medical Colleges (2014) recommends an E-AM model for admission review that considers individual Experiences and Attributes as well as traditional academic Metrics. Experiences are defined as the path the applicant has taken prior to application; examples include healthcare or leadership experiences or experiences with adversity or barriers to educational opportunity (Addams, Bletzinger, Sondheimer, White, & Johnson, 2010). Attributes are the desirable skills and abilities an applicant has at the time of entry into the program in addition to personal and demographic characteristics (Addams et al., 2010). Examples include oral and written communication skills, resiliency, race/ethnicity, first generation college student and gender. Traditional academic metrics are quantitative assessments; those that are commonly used in nursing schools include grade point averages, SAT scores, and/or the Test of Essential Academic Skills (TEAS®). A holistic admissions model can be adapted for schools of nursing (Scott & Zerwic, 2015). The American Association of Colleges of Nursing has endorsed such a model and provides a toolkit for schools of nursing to assist in implementation of holistic admissions (American
http://dx.doi.org/10.1016/j.profnurs.2017.08.005 8755-7223/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
2
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
Association of Colleges of Nursing, 2016a). Implementation of this approach is a journey, requiring a cultural shift among faculty and significant changes to admission practices to achieve diversity goals (Scott & Zerwic, 2015). Schools of medicine and dentistry have a decade-long history with holistic admissions (Wells, Brunson, Sinkford, & Valachovic, 2011; Witzburg & Sondheimer, 2013), while pre-licensure schools of nursing have begun a more recent campaign to increase awareness and adoption of this process. This difference was borne out in a 2014 national survey of public universities by the Urban Universities for Health (2014) of 228 health professions schools' admission practices. Over 90% of schools of medicine and dentistry reported using a holistic admission process compared to 47% of baccalaureate schools of nursing. Barriers to implementation of a holistic admission process were identified in focus groups conducted in 2014 with school of nursing deans and/or their designees. Results demonstrated that lack of knowledge of best practices and legal guidelines for holistic admissions, and the need for resources and university administrative support for implementation, were challenges (Glazer et al., 2016). Recommendations from this study included improving knowledge of holistic admissions among nursing deans, university support, faculty and staff diversity training; self-assessment of current admission practices; and further research to identify student factors that are critical to success in nursing. Evidence supports implementation of holistic admissions to improve admission rates of diverse applicants to health professions schools. In the Urban Universities for Health (2014) of holistic admission practices of health professions schools, 81% of schools using many elements of a holistic admission process indicated an increase in the diversity of students compared to 60% of schools using few to no elements of holistic admissions. For schools reporting use of holistic admissions practices, 90% reported that the average GPAs of incoming students were either increased or unchanged, 96% reported that graduation rates were increased or unchanged, and 97% reported that graduating GPAs of students were increased or unchanged. In addition, schools using holistic admissions were overwhelmingly more likely to report their students were increasingly engaged in the community, demonstrated better teamwork and cooperation, and were more open to ideas and perspectives different than their own compared to schools not using a holistic admission process. In a retrospective study of one medical school's admissions over a two year period, researchers conducted an analysis of differential weighting of academic metrics, experiences, and attributes as measured through a Multiple Mini Interview (MMI). Sole reliance on the MMI for admission decisions, after academic metric minimums were met, would have resulted in an increased acceptance rate of underrepresented minorities from 22% to 57% (Terregino, McConnell, & Reiter, 2015). Core principles of holistic admissions The Association of American Medical Colleges (2013) developed four elements or core principles of holistic admissions, which American Association of Colleges of Nursing (2016b) has endorsed for nursing. These four core principles are: 1. Selection criteria are broad-based, clearly linked to school mission and goals, and promote diversity as an essential element to achieving institutional excellence. 2. A balance of applicant experiences, attributes, and academic metrics (E-A-M) a. Is used to assess applicants with the intent of creating a richly diverse interview and selection pool and student body; b. Is applied equitably across the entire candidate pool c. Is grounded in data that provide evidence supporting the use of selection criteria beyond grades and test scores. 3. Admissions staff and committee members give individualized consideration to how each applicant may contribute to the school
learning environment and to the profession, weighing and balancing the range of criteria needed in a class to achieve the outcomes desired by the school. 4. Race and ethnicity may be considered as factors (under federal law and where permitted by state law) when making admission-related decisions only when such consideration is narrowly tailored to achieve mission-related educational interests and goals associated with student diversity, and when considered as part of a broader mix of factors, which may include personal attributes, experiential factors, demographics, or other considerations Core principle one Best practices for holistic admissions include recommendations to review admission selection criteria to determine if and how they are linked to university and school missions (American Association of Colleges of Nursing, 2016b; Association of American Medical Colleges, 2013). Do school and university missions speak to diversity as key to achieving excellence and is diversity a component of the admission review? A key strategy recommended to achieve this principle is the development of an admissions mission statement that includes diversity and clearly identifies the characteristics of an applicant that will contribute to becoming a successful member of the profession. Examples of mission-related criteria assessed by schools surveyed in the Urban Universities for Health (2014) included an applicant focus on rural or urban underserved communities, primary care, global health, and research. Another recommended strategy is to broaden the composition of admission review committees to include members of the community and, in particular, those who represent the diversity goals of the school. Wells et al. (2011) identify that dental schools who have most successfully implemented holistic admissions have a diverse admission review committee. They suggest inviting diverse practitioners, alumni, and faculty from other university schools in addition to university diversity and inclusion staff. It is also recommended to provide training to the admission review committee on the school's mission and goals, the value of diversity to the school and profession, and unconscious bias. Implementing workshops for admission review committees can facilitate understanding of the process by all members of the committee. Such workshops can be specifically tailored to a school (Scott & Zerwic, 2015) or a profession. For example, Wells et al. (2011) describe a workshop for schools of dentistry provided by The American Dental Education Association on holistic admission practices. Core principle two Development of an E-A-M model to assess candidates is the second core principle of holistic admissions with consideration of the weighting of academic metrics and non-academic factors. Examples of non-academic diversity factors identified by schools using holistic admissions (Urban Universities for Health, 2014) include applicant community of origin from a medically underserved area or a geographic target of the school, foreign language ability, first-generation college student, race/ ethnicity (as permitted by law), socioeconomic status, experience with underserved populations, and gender. Interviewing applicants is one method to evaluate non-academic factors. Admission interviews, either group or individual, can evaluate how the individual applicant's attributes and experiences align with the school's mission and important characteristics needed for success in the profession. For example, since the ability to work in teams is a core competency for health team members (Greiner & Knebel, 2003), Felix et al. (2012, p.24) asked physician assistant applicants, “What experience have you had working in groups and what did you learn about yourself?” Other examples of interview questions that assess individual attributes and experiences are questions that ask about their
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
understanding of the role of the profession they are about to enter, how they have dealt with stress, adversity, or disappointment (to assess resiliency), and questions related to school mission and values, such as leadership and community service experiences (Scott & Zerwic, 2015; Wilson, Sedlacek, & Lowery, 2014). Regular evaluation of data is recommended to identify if admission outcomes are meeting school mission and goals. Collecting data on admission application, matriculation and graduation to capture student experiences and attributes that align with school mission and goals is critical to assessment achievement in meeting holistic admission outcomes (American Association of Colleges of Nursing, 2016c). Attention should be given to the point in the application process when academic metric and non-academic factors are reviewed. For example, consideration of non-academic factors earlier in the applicant review process at initial screening is recommended as part of a holistic admission process rather than applying academic metrics first to qualify applicants (Addams et al., 2010). While this may be difficult to achieve with large numbers of applicants, Urban Universities for Health (2014) identifies applying a review equitably across the candidate pool, such as interviewing all qualified candidates, as another best practice. Core principle three It is recommended that admission review committees assess how the individual applicant can contribute to the school and the profession, and the overall composition of the admitted class should be evaluated to determine how it meets the institution's mission and goals (Urban Universities for Health, 2014). Balancing the weight of academic metrics and non-academic factors should be evaluated to meet diversity (Terregino et al., 2015). Consideration of moving qualified candidates who have not made the cut for interview or are on the waitlist forward to an interview is a recommended strategy to achieve diversity goals (Urban Universities for Health, 2014). Core principle four Federal law allows for consideration of race and ethnicity among non-academic factors when schools can demonstrate that this consideration is necessary to meet the mission and goals of the school (American Association of Colleges of Nursing, 2016d). State law must also be considered in seven states (Washington, Michigan, Nebraska, Arizona, New Hampshire, California and Florida) that either fully or partially prohibit the consideration of race and ethnicity in admission decisions (Urban Universities for Health, 2014). It is recommended to consult with university legal resources when developing a holistic admission process. One school's journey Oregon Health & Science University (OHSU) is the only academic health center in Oregon and the School of Nursing (SON) is the only public school of nursing with undergraduate and graduate programs offered statewide. The pre-licensure baccalaureate programs are located on the OHSU Portland campus and four regional campuses, three of which are in rural areas, are situated on host public university campuses. OHSU undergraduate nursing program is part of an academic progression partnership with 11 community college nursing programs, called the Oregon Consortium for Nursing Education (2017). Certain admission criteria, including academic metrics and non-academic factors, were developed collaboratively and are similar across all partner programs with the opportunity to individualize other admission criteria based on mission and values. OHSU is committed to diversifying the health professions workforce as stated in OHSU's Vision 2020 Strategic Goal 1 to “Be a great organization, diverse in people and ideas” and a strategy for that goal to “foster a culturally proficient, inclusive and diverse workforce” (Oregon Health &
3
Science University, 2014). In fulfillment of that vision, an OHSU 2013 Diversity Action Plan (OHSU, 2013) created a framework to meet OHSU's commitment to supporting and sustaining a diverse and inclusive learning, living and working environment and identified diversity as central to OHSU's core values and essential to meeting its mission. The first goal in the university framework for the plan is to “Increase recruitment and representation of diverse students, residents, fellows, faculty and the workforce throughout OHSU” (Oregon Health & Science University, 2013, p.11). Holistic admissions practices were recommended strategies to achieve that goal. Each school at the university was asked to develop a diversity action plan using this common framework. The SON affirmed its commitment to student diversity through several mechanisms, including the development of an admission mission statement and the SON Diversity Action Plan. A SON Diversity Admissions Taskforce was formed consisting of faculty and admissions personnel to create the statement which was approved by the SON faculty in January 2013 (see Table 1). The SON Diversity Action Plan, developed by a task force made up of SON faculty, staff and student, was approved by the SON faculty in 2014 and included strategies for continued development of holistic admissions to increase the relative number of disadvantaged and underrepresented students across programs and campuses. Regular evaluation of goals and metrics were established through reporting mechanisms back to the university which created accountability for the plan. An SON Diversity Advisory Group consisting of SON faculty, staff and student representatives, updated the document in 2017 and is charged with ensuring implementation of the plan. Following the implementation of the admissions mission statement in 2013, the admissions office initiated data collection for all applicants that included a comprehensive list of factors related to educational and economic disadvantage. Baseline and annual admissions data have been tracked since 2013 on the following factors: gender, race/ethnicity; first generation college student, socioeconomic status, zip code of high school (to determine rates for free lunch, graduation, SAT scores), rural residence, and veteran status. Disadvantaged students are identified as those who have experienced educational or economical adversity that may be a barrier to academic success, including those who are underrepresented in nursing. Current process Holistic admissions has been implemented for 4 admission cycles for undergraduate programs at the academic health center in urban Portland and for undergraduate programs on the four regional campuses. The school website informs prospective applicants that the holistic admission process includes an interview to assess how applicants have the potential to meet our admission missions and values. The SON Admissions Mission and Values Statement is available on the admission website. Specific information regarding calculation of admission scores and the process for making final decisions is not shared
Table 1 School of nursing admissions mission and values statement. • Admissions Vision: A dynamic learning community made up of students and faculty with diverse perspectives and backgrounds in an academic environment that fosters the development of compassion, humanism, professionalism, and cultural competence. • Admissions Mission: To actively recruit and retain highly qualified and diverse students in all nursing programs and campuses. • Admissions Values: Applicants who demonstrate: 1) academic, professional, and/or leadership excellence that indicates a potential for success in the education program and in nursing practice, education and research; 2) vision, motivation, and understanding of the nursing profession and the broad spectrum of nursing roles: and, 3) potential to enhance, broaden, and contribute a diverse perspective to the experiences of students and faculty in education, practice, and research.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
4
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
publicly. Since reporting demographic information on application cannot legally be required, an optional supplemental section at initial application requests information related to student experiences and attributes. All campuses have implemented an interview process modified to the specific capacity and preference of each campus, incorporating either mini-multiple or group interviews. Interview procedures, including questions and rubrics, were developed based on McMaster University School of Medicine guidelines (McMaster University, 2017). Essay and interview questions include assessment of student experiences and attributes, and were developed based on OHSU and SON mission and value statements and state-legislated key performance measures identified for the university. Faculty developed a pool of standard questions for each interview station. Rubrics were created for scoring all interview stations. Table 2 outlines the experiences, attributes, and academic metrics used to evaluate candidates. On all campuses, 200% of the available seats in a program are invited to interview. For example, if a program was admitting 32 students, 64 students would be invited to interview. Certain non-academic factors are evaluated in the initial screening of the applicant before invitation to interview while others are assessed at interview. For example, factors related to educational disadvantage, such as experiences with adversity, rural or state residency, and first generation college student, are assessed on the application through self-reported demographic assessment and short essays. Healthcare experience and host campus attendance are documented by supervisor report of hours worked and transcripts, respectively. At interview, applicants' short essays regarding social justice and leadership experiences are assessed by rubric. Currently, because of logistics and the large number of applicants at certain campuses, not all qualified applicants are interviewed, which has influenced the make-up of the cohort. Results Comprehensive data collection at application allows for better understanding of students are and how they align with the mission and goals of the SON. For example, the expanded demographic information collected beginning in 2013 provided us with more accurate information about undergraduate students who have experienced economic or educational disadvantage in pursuing their career goals. This information assists the SON in being proactive in prevising resources and support. Admissions and retention data are reported to administrators and faculty annually, and each program receives a dashboard describing the number and percentage of disadvantaged and underrepresented students who apply, are admitted, and matriculate into the program. These data are used to evaluate the effectiveness of admissions practices and policies towards achieving diversity goals and revise strategies. Approximately 70% of undergraduate students have one or more
educational or economic factors that would characterize them as economically or educationally disadvantaged (See Fig. 1). Demographic data collection prior to 2013 did not adequately provide a comprehensive assessment of disadvantaged status, as evidenced by the large jump between 2013 and 2014. The percentage of underrepresented minority students matriculating into undergraduate programs grew steadily from a baseline of 11% of the cohort in 2013 to 16% of the cohort in 2016. Retention and graduation rates of disadvantaged and URM students have risen steadily to over 90%. While the interview process is time-intensive, faculty believe it is well worth the time invested. Interacting with applicants provides an opportunity for faculty to get to know students prior to admission and the interview provides beneficial information and insight that is not captured in an application essay. Applicants are provided an opportunity to tour the campus and speak with students and faculty. This allows applicants to assess their fit with the school. Lessons learned The following lessons and recommendations of our experience may be of assistance to other schools implementing holistic admissions. • Start with an admissions mission statement. Reviewing documents at your institution related to mission, vision and diversity provides a foundation and support for this initial work. Consulting with internal partners, such as diversity resources and legal resources, can provide additional expertise. School of Medicine colleagues provided guidance on the implementation of admission interviews and allowed us to participate on their interview committees to gain experience with the process. • Access best practices and experts. External resources include professional healthcare organizations, university websites, and conferences on Holistic Admissions. External consultants are also available to provide workshops and to review and advise on developing policy and procedures. • Identify champions and early adapters. Administrative and faculty buy-in is essential to success. An internal structure that includes faculty, staff, and administrative champions is an effective approach to introducing and advancing the work. Taskforces at OHSU SON developed the School of Nursing Admissions Mission and Values Statement and Diversity Action Plans. The Diversity Action Plan and Diversity Advisory Group assist us to keep our work moving forward. • Use data to evaluate progress and adjust the plan. Ongoing and comprehensive data collection and analysis was helpful in overcoming barriers to holistic admissions, such as concerns about the success of disadvantaged students. Providing data dashboards about retention and graduation success of disadvantaged students was powerful in
Table 2 Undergraduate experiences, attributes and academic metrics for admission. Experiences Assessed at initial screen
Assessed at Interview
• Experiences with adversity (economic, educational, ethnic/cultural, family) • Paid or volunteer healthcare experiences • Coming from host campus (for regional campus applicants) • State resident • Rural resident • First generation college student • Underrepresented minority • Leadership experiences • Experience with diverse or underserved population
Attributes
Academic metrics • GPA • Completion of specific prerequisites by application deadline • Additional degrees • Completion of chemistry
• • • • • • •
Commitment to Social Justice Oral Communication Written Communication Values that align with the profession Motivational fit for the profession Ability to tolerate stress Ability to learn from experiences
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
5
Fig. 1. Aggregate incoming class data on disadvantaged and underrepresented minority status in undergradaute programs.
•
•
changing perceptions and motivating faculty to learn more about applicants. Review incomplete applications for bias. Some disadvantaged students may not fully understand the importance of attending to details in their application, and as a result, their applications may be incomplete. For example, information regarding educational and economic disadvantage is collected via a supplemental, optional section. Some of the most disadvantaged students did not submit that portion of the application because it was optional. Instructions have been added to the application explaining the benefits of completing this supplemental section. Providing informational sessions on application completion is also a recommended practice. It's a journey. A key lesson learned is that the holistic admission process is a dynamic, iterative process so frequent evaluation of the process is recommended. For example, when we first added interviews, one question was developed for each station. Based on feedback from faculty, interviewers and experience with repeat applicants, a pool of questions for each station was developed by faculty and used statewide. Piloting new admissions practices was also found to be helpful prior to full implementation of a change. For example, one campus recently piloted adding diverse community partners to the admission review committee to identify strengths and challenges prior to full implementation. This pilot is in the process of being evaluated and shared with other programs.
Next steps With the full support of SON administration, faculty continue to reevaluate and update admission criteria based on evaluation of diversity goal attainment; there is still much work to do. Part of the iterative process includes determining the optimal balance of academic metrics and non-academic factors into admission decisions. Current admission practices are being compared to recommended best practices to identify gaps, such as focusing essay and interview questions more specifically on the OHSU SON mission and values; providing faculty development on unconscious bias; improving the reliability of admission rubrics; and, reconfiguring admissions committees. Holistic admissions best practices are currently being implemented throughout the SON, including in graduate programs. Ongoing evaluation of data includes determining which prospective students don't complete applications and comparing characteristics of both admitted and non-admitted students to identify disparities. A checklist of best practices has been developed for internal self-assessment by faculty admission committees (See Table 3). (American Association of Colleges of Nursing, 2016b; Association of American Medical Colleges, 2013; Glazer et al., 2015; Glazer et al., 2016; Scott & Zerwic, 2015; Urban Universities for Health, 2014).
Summary Data demonstrate that the SON has increased the number and percentage of underrepresented minority and disadvantaged students in undergraduate programs over the past 3 years. The diversity of undergraduate cohorts has increased with even modest changes in the admissions procedures. Holistic admissions is an important component of a diversity plan and is one element of a comprehensive plan of strategies to diversify the nursing workforce that must address recruitment, admission, retention, and graduation (Noone, Wros, Najjar, Cortez, & Magdaleno, 2016). Holistic admissions is a dynamic process to achieve Table 3 Holistic admissions checklist. Admissions mission School has an admissions mission statement that includes diversity. Selection criteria Selection criteria include an evidence-based balance of applicant experiences, attributes, and academic metrics. Selection criteria are linked to the university and SON mission/values. Initial screening includes evaluation of non-academic criteria (identify dimensions of diversity and disadvantage to be considered such as first generation college student, socioeconomic status, urban/rural community of origin, gender, race, foreign language ability). Selection criteria consider potential contributions to the learning community and the profession. The relative weight of each area (applicant experiences, attributes and academic metrics) is considered in contributing to the total score. Admissions committee The admissions committee is broadened to include diverse individuals. Admissions committee (reviewers, interviewers, and decision-makers) participate in unconscious bias training. Admissions process Essay questions address the school's mission and values. Essay questions are designed to identify students who are educationally or economically disadvantaged. Non-academic criteria are assessed after students have met the minimum criteria for admission. The admissions process includes interviews (group or individual). Essay and interview questions are standardized. A rubric is used to rate and document rankings on selection criteria. Admissions committees have the opportunity to discuss applicants. Admissions decisions include consideration of the overall diversity of the class. Students are selected from the waitlist by criteria related to the mission/values. Evaluation plan Evaluate demographics characteristics of students offered admission to those not to identify disparities. Regularly evaluate if outcomes are achieving SON admission mission and revise application process accordingly.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
6
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
university and school missions, and represents a culture shift away from predominantly (or often exclusively) valuing academic metrics of student success to a balanced consideration of academic metrics, student attributes, and experiences that will contribute to the learning community and the nursing workforce. References Addams, A. N., Bletzinger, R. B., Sondheimer, H. M., White, S. E., & Johnson, L. M. (2010). Roadmap to diversity: Integrating holistic review practices into medical school admission processes. Washington, DC: American Association of Medical Colleges. American Association of Colleges of Nursing (2016a). Holistic admissions review in nursing. Retrieved from http://www.aacnnursing.org/Education-Resources/ToolKits/Holistic-Admissions-Tool-Kit . American Association of Colleges of Nursing (2016b). Holistic review: A quick primer. Retrieved from http://urbanuniversitiesforhealth.org/media/documents/Holistic_ Review_Primer.pdf. American Association of Colleges of Nursing (2016c). Holistic review in nursing — An introduction. [Video file]. Retrieved from https://www.youtube.com/watch?v= 0Zt_TfX7KoU&feature=youtu.be. American Association of Colleges of Nursing (2016d). Legal requirements for institutions using race and ethnicity-conscious policies. Retrieved from http:// urbanuniversitiesforhealth.org/media/documents/Legal_Requirements_for_ Institutions_Using_Race_and_Ethnicity-Conscious_Policies.pdf. American Association of Medical Colleges (2014). Advancing holistic review initiative. Retrieved from https://www.aamc.org/download/358384/data/holisticreviewbrochure. pdf. Association of American Medical Colleges (2013). Roadmap to excellence: Key concepts for evaluating the impact of medical school holistic admissions. Retrieved from https://members.aamc.org/eweb/upload/Holistic%20Review%202013.pdf. Felix, H., Laird, J., Ennulat, C., Donkers, K., Garrubba, C., Hawkins, S., & Hertweck, M. (2012). Holistic admissions process: An initiative to support diversity in medical education. Journal of Physician Assistant Education, 23(3), 21–27. Glazer, G., Clark, A., & Bankston, K. (2015). Legislative: From policy to practice: A case for holistic review diversifying the nursing workforce. Online J Issues Nurs, 20(3), 1. http://dx.doi.org/10.3912/OJIN.Vol20No03LegCol01. Glazer, G., Clark, A., Bankston, K., Danek, J., Fair, M., & Michaels, J. (2016). Holistic admissions in nursing: We can do this. J Prof Nurs, 32(4), 306-213. Goodfellow, A., Ulloa, J. G., Dowling, P. T., Talamantes, E., Chheda, S., Bone, C., & Moreno, G. (2016). Predictors of primary care physician practice location in underserved urban or rural areas in the United States: A systematic literature review. Acad Med, 91(9), 1313–1321. Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Hayes-Bautista, T. M., Schink, W., & Hayes-Bautista, D. E. (2016). Latino nurses in the United States: An overview of three decades (1980–2010). Am J Nurs, 116(2), 24–33. Komaromy, M., Grumback, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A. B. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med, 334(20), 1305–1310.
Marrast, L. M., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians' role in the care of underserved patients: Diversifying the physician workforce may be key in addressing health disparities. J Am Med Assoc, 174(2), 289–291. McMaster University (2017). Admission manual for reviewers. Retrieved from http:// mdprogram.mcmaster.ca/docs/default-source/admissions/interviewer-manualmmi_websiteversion.pdf?sfvrsn=2. Noone, J., Wros, P., Najjar, R., Cortez, D., & Magdaleno, L. (2016). Advancing health equity through student empowerment & professional success: A state-wide approach. J Nurs Educ, 55(6), 316–322. http://dx.doi.org/10.3928/01484834-20160516-03. Oregon Consortium for Nursing Education (2017). Welcome to the Oregon Consortium for Nursing Education (OCNE). Retrieved from www.ocne.org. Oregon Health Authority (2014). The Diversity of Oregon’'s Healthcare Workforce 2012—2013. http://www.oregon.gov/oha/HPA/ANALYTICS/HealthCareWorkforceReporting/20122013-Oregon%27s-health-care-workforce-diversity.pdf. Oregon Health & Science University (2013). OHSU diversity action plan 2013: Creating a community of diversity and inclusion. Retrieved from http://www.ohsu.edu/xd/ about/vision/center-for-diversity-inclusion/about/upload/OHSU_Diversity_Action_ Plan_2013.pdf. Oregon Health & Science University (2014). OHSU vision 2020 v. 2013: OHSU strategic plan 2013-2017. Retrieved from http://www.ohsu.edu/xd/about/vision/upload/ OHSU-Vision2020v2013for-Board-FINAL-Jan-30.pdf. Oregon Health Authority and Department of Human Services (2013). State of Equity Report Phase 2. http://www.oregon.gov/oha/oei/reports/State%20of%20Equity% 20Report%20-%20Phase%20II%20-%20September%202013.pdf. Saha, S., Taggart, S. H., Komaromy, M., & Bindman, A. B. (2000). Do patients choose physicians of their own race? Health Aff, 19(4), 76–83. Scott, L. D., & Zerwic, J. (2015). Holistic review in admissions: A strategy to diversify the nursing workforce. Nurs Outlook, 63, 488–495. Smedley, B. D., Stith Butler, A., & Bristow, L. R. (Eds.). (2004). In the nation's compelling interest: Ensuring diversity in the health-care workforce. Washington, DC: The National Academies Press. Terregino, C. A., McConnell, M., & Reiter, H. I. (2015). The effect of differential weighting of academics, experiences, and competencies measured by multiple mini interview (MMI) on race and ethnicity of cohorts accepted to one medical school. Acad Med, 90(12), 1651–1657. U.S. Department of Health and Human Services (2015). Sex, race and ethnic diversity of U. S. health occupations (2010− 2012). Retrieved from https://bhw.hrsa.gov/sites/ default/files/bhw/nchwa/diversityushealthoccupations.pdf. Urban Universities for Health (2014). Holistic admissions in the health professions: Findings from a national survey. Retrieved from http://urbanuniversitiesforhealth.org/ media/documents/holisticadmissionsinthehealthprofessions.pdf. Wells, A., Brunson, D., Sinkford, J. C., & Valachovic, R. W. (2011). Working with dental school admissions committees to enroll a more diverse student body. J Dent Educ, 75(5), 685–695. Wilson, M. B., Sedlacek, W. E., & Lowery, B. L. (2014). An approach to using noncognitive variables in dental school admissions. J Dent Educ, 78(4), 567–574. Witzburg, R. A., & Sondheimer, H. M. (2013). Holistic review—Shaping the medical profession one applicant at a time. N Engl J Med, 368(17), 1565–1567. Xue, Y., & Brewer, C. (2014). Racial and ethnic diversity of the U.S. national nurse workforce 1988–2013. Policy, Politics and Nursing Practice, 15(3/4), 102–110.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
Contents lists available at ScienceDirect
Journal of Professional Nursing
Holistic admissions in undergraduate nursing: One school's journey and lessons learned Peggy Wros a, Joanne Noone b,⁎ a b
Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Road, Portland, OR 97239, United States Oregon Health & Science University, School of Nursing, 1250 Siskiyou Boulevard, Ashland, OR 97520, United States
Background on nursing workforce diversity Improving the diversity of the nursing workforce is a key strategy for achieving culturally effective, patient-centered care and health equity (Smedley, Stith Butler, & Bristow, 2004). While the term “diversity” is generally interpreted broadly, data regarding minorities in the nursing workforce have been widely reported. Minority health care providers are more likely to work in underserved areas and provide care for minority populations (Goodfellow et al., 2016; Komaromy et al., 1996; Marrast et al., 2014). Minority patients are more likely to choose a healthcare provider of their own race or ethnicity because of personal preference and language concordance (Saha et al., 2000). It is encouraging that the numbers of minority nurses are increasing in the nursing workforce; however, the minority distribution of registered nurses (RNs) in the United States (U·S.) is not representative of the working population (U.S. Department of Health and Human Services, 2015). For example, black Americans constitute 13.6% of the workforce but only 10.7% of the registered nursing workforce. The disparity is even wider for registered nurses of Hispanic or Latino background with approximately 15.5% of the working population identified as Latino compared with 5.4% of registered nurses (U.S Department of Health and Human Services, 2015). Two recent analyses have identified a widening gap for minority nurses, in particular Hispanic nurses, as compared to the nursing workforce and the U.S. population growth. In a recent comparison of census data from 1980 to 2010, the U.S. Latino population tripled during those three decades, from 14.8 million to 50.7 million. During that same period, the Latino RN population grew by only a third from 213 Latino RNs per 100,000 Latinos in 1980 to 311 Latino RNs per 100,000 Latinos in 2010 (Hayes-Bautista, Schink, & Hayes-Bautista, 2016). Xue and Brewer (2014) analyzed data from the 1988 through 2013 from the National Sample Survey of Registered Nurses from 1988 to 2008 and the 2013 National Workforce Survey of Registered Nurses. The minority RN population grew from 7.7% to 18% during that time period while the U.S. minority population grew from 23.5% in 1988 to 37.3% in 2013. In comparing minority RN workforce to total population, there was a gap of 15.8% in 1988 that worsened to 19.3% in 2013. In an analysis of state data from the 2008 National Sample Survey of Registered Nurses, Oregon was identified as a state with a gap in Hispanic ⁎ Corresponding author. E-mail addresses: [email protected] (P. Wros), [email protected] (J. Noone).
representation in the nursing workforce as compared to the population (Xue & Brewer, 2014), with approximately 12% of the population in Oregon as Hispanic compared to 4% of the nursing workforce (Oregon Health Authority, 2014). Lack of diversity in the healthcare workforce has been identified by Oregon state health officials as a contributing factor to health inequity for Hispanic populations (Oregon Health Authority, 2013). Holistic admissions is a strategy currently being recommended by health professions education organizations to improve workforce diversity (American Association of Colleges of Nursing, 2016a; American Association of Medical Colleges, 2014). The purpose of this paper is to outline current recommended practices for implementation of a holistic admission process and describe one school of nursing's journey, including lessons learned, to implement holistic admissions in their undergraduate program. What is holistic admissions? Holistic admissions provides more equitable opportunities for educationally and economically disadvantaged students to enter nursing (Glazer, Clark, & Bankston, 2015) by considering an applicant's individual characteristics, background, and potential for contributing to the school and the profession in addition to more common academic criteria (American Association of Medical Colleges, 2014). The American Association of Medical Colleges (2014) recommends an E-AM model for admission review that considers individual Experiences and Attributes as well as traditional academic Metrics. Experiences are defined as the path the applicant has taken prior to application; examples include healthcare or leadership experiences or experiences with adversity or barriers to educational opportunity (Addams, Bletzinger, Sondheimer, White, & Johnson, 2010). Attributes are the desirable skills and abilities an applicant has at the time of entry into the program in addition to personal and demographic characteristics (Addams et al., 2010). Examples include oral and written communication skills, resiliency, race/ethnicity, first generation college student and gender. Traditional academic metrics are quantitative assessments; those that are commonly used in nursing schools include grade point averages, SAT scores, and/or the Test of Essential Academic Skills (TEAS®). A holistic admissions model can be adapted for schools of nursing (Scott & Zerwic, 2015). The American Association of Colleges of Nursing has endorsed such a model and provides a toolkit for schools of nursing to assist in implementation of holistic admissions (American
http://dx.doi.org/10.1016/j.profnurs.2017.08.005 8755-7223/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
2
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
Association of Colleges of Nursing, 2016a). Implementation of this approach is a journey, requiring a cultural shift among faculty and significant changes to admission practices to achieve diversity goals (Scott & Zerwic, 2015). Schools of medicine and dentistry have a decade-long history with holistic admissions (Wells, Brunson, Sinkford, & Valachovic, 2011; Witzburg & Sondheimer, 2013), while pre-licensure schools of nursing have begun a more recent campaign to increase awareness and adoption of this process. This difference was borne out in a 2014 national survey of public universities by the Urban Universities for Health (2014) of 228 health professions schools' admission practices. Over 90% of schools of medicine and dentistry reported using a holistic admission process compared to 47% of baccalaureate schools of nursing. Barriers to implementation of a holistic admission process were identified in focus groups conducted in 2014 with school of nursing deans and/or their designees. Results demonstrated that lack of knowledge of best practices and legal guidelines for holistic admissions, and the need for resources and university administrative support for implementation, were challenges (Glazer et al., 2016). Recommendations from this study included improving knowledge of holistic admissions among nursing deans, university support, faculty and staff diversity training; self-assessment of current admission practices; and further research to identify student factors that are critical to success in nursing. Evidence supports implementation of holistic admissions to improve admission rates of diverse applicants to health professions schools. In the Urban Universities for Health (2014) of holistic admission practices of health professions schools, 81% of schools using many elements of a holistic admission process indicated an increase in the diversity of students compared to 60% of schools using few to no elements of holistic admissions. For schools reporting use of holistic admissions practices, 90% reported that the average GPAs of incoming students were either increased or unchanged, 96% reported that graduation rates were increased or unchanged, and 97% reported that graduating GPAs of students were increased or unchanged. In addition, schools using holistic admissions were overwhelmingly more likely to report their students were increasingly engaged in the community, demonstrated better teamwork and cooperation, and were more open to ideas and perspectives different than their own compared to schools not using a holistic admission process. In a retrospective study of one medical school's admissions over a two year period, researchers conducted an analysis of differential weighting of academic metrics, experiences, and attributes as measured through a Multiple Mini Interview (MMI). Sole reliance on the MMI for admission decisions, after academic metric minimums were met, would have resulted in an increased acceptance rate of underrepresented minorities from 22% to 57% (Terregino, McConnell, & Reiter, 2015). Core principles of holistic admissions The Association of American Medical Colleges (2013) developed four elements or core principles of holistic admissions, which American Association of Colleges of Nursing (2016b) has endorsed for nursing. These four core principles are: 1. Selection criteria are broad-based, clearly linked to school mission and goals, and promote diversity as an essential element to achieving institutional excellence. 2. A balance of applicant experiences, attributes, and academic metrics (E-A-M) a. Is used to assess applicants with the intent of creating a richly diverse interview and selection pool and student body; b. Is applied equitably across the entire candidate pool c. Is grounded in data that provide evidence supporting the use of selection criteria beyond grades and test scores. 3. Admissions staff and committee members give individualized consideration to how each applicant may contribute to the school
learning environment and to the profession, weighing and balancing the range of criteria needed in a class to achieve the outcomes desired by the school. 4. Race and ethnicity may be considered as factors (under federal law and where permitted by state law) when making admission-related decisions only when such consideration is narrowly tailored to achieve mission-related educational interests and goals associated with student diversity, and when considered as part of a broader mix of factors, which may include personal attributes, experiential factors, demographics, or other considerations Core principle one Best practices for holistic admissions include recommendations to review admission selection criteria to determine if and how they are linked to university and school missions (American Association of Colleges of Nursing, 2016b; Association of American Medical Colleges, 2013). Do school and university missions speak to diversity as key to achieving excellence and is diversity a component of the admission review? A key strategy recommended to achieve this principle is the development of an admissions mission statement that includes diversity and clearly identifies the characteristics of an applicant that will contribute to becoming a successful member of the profession. Examples of mission-related criteria assessed by schools surveyed in the Urban Universities for Health (2014) included an applicant focus on rural or urban underserved communities, primary care, global health, and research. Another recommended strategy is to broaden the composition of admission review committees to include members of the community and, in particular, those who represent the diversity goals of the school. Wells et al. (2011) identify that dental schools who have most successfully implemented holistic admissions have a diverse admission review committee. They suggest inviting diverse practitioners, alumni, and faculty from other university schools in addition to university diversity and inclusion staff. It is also recommended to provide training to the admission review committee on the school's mission and goals, the value of diversity to the school and profession, and unconscious bias. Implementing workshops for admission review committees can facilitate understanding of the process by all members of the committee. Such workshops can be specifically tailored to a school (Scott & Zerwic, 2015) or a profession. For example, Wells et al. (2011) describe a workshop for schools of dentistry provided by The American Dental Education Association on holistic admission practices. Core principle two Development of an E-A-M model to assess candidates is the second core principle of holistic admissions with consideration of the weighting of academic metrics and non-academic factors. Examples of non-academic diversity factors identified by schools using holistic admissions (Urban Universities for Health, 2014) include applicant community of origin from a medically underserved area or a geographic target of the school, foreign language ability, first-generation college student, race/ ethnicity (as permitted by law), socioeconomic status, experience with underserved populations, and gender. Interviewing applicants is one method to evaluate non-academic factors. Admission interviews, either group or individual, can evaluate how the individual applicant's attributes and experiences align with the school's mission and important characteristics needed for success in the profession. For example, since the ability to work in teams is a core competency for health team members (Greiner & Knebel, 2003), Felix et al. (2012, p.24) asked physician assistant applicants, “What experience have you had working in groups and what did you learn about yourself?” Other examples of interview questions that assess individual attributes and experiences are questions that ask about their
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
understanding of the role of the profession they are about to enter, how they have dealt with stress, adversity, or disappointment (to assess resiliency), and questions related to school mission and values, such as leadership and community service experiences (Scott & Zerwic, 2015; Wilson, Sedlacek, & Lowery, 2014). Regular evaluation of data is recommended to identify if admission outcomes are meeting school mission and goals. Collecting data on admission application, matriculation and graduation to capture student experiences and attributes that align with school mission and goals is critical to assessment achievement in meeting holistic admission outcomes (American Association of Colleges of Nursing, 2016c). Attention should be given to the point in the application process when academic metric and non-academic factors are reviewed. For example, consideration of non-academic factors earlier in the applicant review process at initial screening is recommended as part of a holistic admission process rather than applying academic metrics first to qualify applicants (Addams et al., 2010). While this may be difficult to achieve with large numbers of applicants, Urban Universities for Health (2014) identifies applying a review equitably across the candidate pool, such as interviewing all qualified candidates, as another best practice. Core principle three It is recommended that admission review committees assess how the individual applicant can contribute to the school and the profession, and the overall composition of the admitted class should be evaluated to determine how it meets the institution's mission and goals (Urban Universities for Health, 2014). Balancing the weight of academic metrics and non-academic factors should be evaluated to meet diversity (Terregino et al., 2015). Consideration of moving qualified candidates who have not made the cut for interview or are on the waitlist forward to an interview is a recommended strategy to achieve diversity goals (Urban Universities for Health, 2014). Core principle four Federal law allows for consideration of race and ethnicity among non-academic factors when schools can demonstrate that this consideration is necessary to meet the mission and goals of the school (American Association of Colleges of Nursing, 2016d). State law must also be considered in seven states (Washington, Michigan, Nebraska, Arizona, New Hampshire, California and Florida) that either fully or partially prohibit the consideration of race and ethnicity in admission decisions (Urban Universities for Health, 2014). It is recommended to consult with university legal resources when developing a holistic admission process. One school's journey Oregon Health & Science University (OHSU) is the only academic health center in Oregon and the School of Nursing (SON) is the only public school of nursing with undergraduate and graduate programs offered statewide. The pre-licensure baccalaureate programs are located on the OHSU Portland campus and four regional campuses, three of which are in rural areas, are situated on host public university campuses. OHSU undergraduate nursing program is part of an academic progression partnership with 11 community college nursing programs, called the Oregon Consortium for Nursing Education (2017). Certain admission criteria, including academic metrics and non-academic factors, were developed collaboratively and are similar across all partner programs with the opportunity to individualize other admission criteria based on mission and values. OHSU is committed to diversifying the health professions workforce as stated in OHSU's Vision 2020 Strategic Goal 1 to “Be a great organization, diverse in people and ideas” and a strategy for that goal to “foster a culturally proficient, inclusive and diverse workforce” (Oregon Health &
3
Science University, 2014). In fulfillment of that vision, an OHSU 2013 Diversity Action Plan (OHSU, 2013) created a framework to meet OHSU's commitment to supporting and sustaining a diverse and inclusive learning, living and working environment and identified diversity as central to OHSU's core values and essential to meeting its mission. The first goal in the university framework for the plan is to “Increase recruitment and representation of diverse students, residents, fellows, faculty and the workforce throughout OHSU” (Oregon Health & Science University, 2013, p.11). Holistic admissions practices were recommended strategies to achieve that goal. Each school at the university was asked to develop a diversity action plan using this common framework. The SON affirmed its commitment to student diversity through several mechanisms, including the development of an admission mission statement and the SON Diversity Action Plan. A SON Diversity Admissions Taskforce was formed consisting of faculty and admissions personnel to create the statement which was approved by the SON faculty in January 2013 (see Table 1). The SON Diversity Action Plan, developed by a task force made up of SON faculty, staff and student, was approved by the SON faculty in 2014 and included strategies for continued development of holistic admissions to increase the relative number of disadvantaged and underrepresented students across programs and campuses. Regular evaluation of goals and metrics were established through reporting mechanisms back to the university which created accountability for the plan. An SON Diversity Advisory Group consisting of SON faculty, staff and student representatives, updated the document in 2017 and is charged with ensuring implementation of the plan. Following the implementation of the admissions mission statement in 2013, the admissions office initiated data collection for all applicants that included a comprehensive list of factors related to educational and economic disadvantage. Baseline and annual admissions data have been tracked since 2013 on the following factors: gender, race/ethnicity; first generation college student, socioeconomic status, zip code of high school (to determine rates for free lunch, graduation, SAT scores), rural residence, and veteran status. Disadvantaged students are identified as those who have experienced educational or economical adversity that may be a barrier to academic success, including those who are underrepresented in nursing. Current process Holistic admissions has been implemented for 4 admission cycles for undergraduate programs at the academic health center in urban Portland and for undergraduate programs on the four regional campuses. The school website informs prospective applicants that the holistic admission process includes an interview to assess how applicants have the potential to meet our admission missions and values. The SON Admissions Mission and Values Statement is available on the admission website. Specific information regarding calculation of admission scores and the process for making final decisions is not shared
Table 1 School of nursing admissions mission and values statement. • Admissions Vision: A dynamic learning community made up of students and faculty with diverse perspectives and backgrounds in an academic environment that fosters the development of compassion, humanism, professionalism, and cultural competence. • Admissions Mission: To actively recruit and retain highly qualified and diverse students in all nursing programs and campuses. • Admissions Values: Applicants who demonstrate: 1) academic, professional, and/or leadership excellence that indicates a potential for success in the education program and in nursing practice, education and research; 2) vision, motivation, and understanding of the nursing profession and the broad spectrum of nursing roles: and, 3) potential to enhance, broaden, and contribute a diverse perspective to the experiences of students and faculty in education, practice, and research.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
4
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
publicly. Since reporting demographic information on application cannot legally be required, an optional supplemental section at initial application requests information related to student experiences and attributes. All campuses have implemented an interview process modified to the specific capacity and preference of each campus, incorporating either mini-multiple or group interviews. Interview procedures, including questions and rubrics, were developed based on McMaster University School of Medicine guidelines (McMaster University, 2017). Essay and interview questions include assessment of student experiences and attributes, and were developed based on OHSU and SON mission and value statements and state-legislated key performance measures identified for the university. Faculty developed a pool of standard questions for each interview station. Rubrics were created for scoring all interview stations. Table 2 outlines the experiences, attributes, and academic metrics used to evaluate candidates. On all campuses, 200% of the available seats in a program are invited to interview. For example, if a program was admitting 32 students, 64 students would be invited to interview. Certain non-academic factors are evaluated in the initial screening of the applicant before invitation to interview while others are assessed at interview. For example, factors related to educational disadvantage, such as experiences with adversity, rural or state residency, and first generation college student, are assessed on the application through self-reported demographic assessment and short essays. Healthcare experience and host campus attendance are documented by supervisor report of hours worked and transcripts, respectively. At interview, applicants' short essays regarding social justice and leadership experiences are assessed by rubric. Currently, because of logistics and the large number of applicants at certain campuses, not all qualified applicants are interviewed, which has influenced the make-up of the cohort. Results Comprehensive data collection at application allows for better understanding of students are and how they align with the mission and goals of the SON. For example, the expanded demographic information collected beginning in 2013 provided us with more accurate information about undergraduate students who have experienced economic or educational disadvantage in pursuing their career goals. This information assists the SON in being proactive in prevising resources and support. Admissions and retention data are reported to administrators and faculty annually, and each program receives a dashboard describing the number and percentage of disadvantaged and underrepresented students who apply, are admitted, and matriculate into the program. These data are used to evaluate the effectiveness of admissions practices and policies towards achieving diversity goals and revise strategies. Approximately 70% of undergraduate students have one or more
educational or economic factors that would characterize them as economically or educationally disadvantaged (See Fig. 1). Demographic data collection prior to 2013 did not adequately provide a comprehensive assessment of disadvantaged status, as evidenced by the large jump between 2013 and 2014. The percentage of underrepresented minority students matriculating into undergraduate programs grew steadily from a baseline of 11% of the cohort in 2013 to 16% of the cohort in 2016. Retention and graduation rates of disadvantaged and URM students have risen steadily to over 90%. While the interview process is time-intensive, faculty believe it is well worth the time invested. Interacting with applicants provides an opportunity for faculty to get to know students prior to admission and the interview provides beneficial information and insight that is not captured in an application essay. Applicants are provided an opportunity to tour the campus and speak with students and faculty. This allows applicants to assess their fit with the school. Lessons learned The following lessons and recommendations of our experience may be of assistance to other schools implementing holistic admissions. • Start with an admissions mission statement. Reviewing documents at your institution related to mission, vision and diversity provides a foundation and support for this initial work. Consulting with internal partners, such as diversity resources and legal resources, can provide additional expertise. School of Medicine colleagues provided guidance on the implementation of admission interviews and allowed us to participate on their interview committees to gain experience with the process. • Access best practices and experts. External resources include professional healthcare organizations, university websites, and conferences on Holistic Admissions. External consultants are also available to provide workshops and to review and advise on developing policy and procedures. • Identify champions and early adapters. Administrative and faculty buy-in is essential to success. An internal structure that includes faculty, staff, and administrative champions is an effective approach to introducing and advancing the work. Taskforces at OHSU SON developed the School of Nursing Admissions Mission and Values Statement and Diversity Action Plans. The Diversity Action Plan and Diversity Advisory Group assist us to keep our work moving forward. • Use data to evaluate progress and adjust the plan. Ongoing and comprehensive data collection and analysis was helpful in overcoming barriers to holistic admissions, such as concerns about the success of disadvantaged students. Providing data dashboards about retention and graduation success of disadvantaged students was powerful in
Table 2 Undergraduate experiences, attributes and academic metrics for admission. Experiences Assessed at initial screen
Assessed at Interview
• Experiences with adversity (economic, educational, ethnic/cultural, family) • Paid or volunteer healthcare experiences • Coming from host campus (for regional campus applicants) • State resident • Rural resident • First generation college student • Underrepresented minority • Leadership experiences • Experience with diverse or underserved population
Attributes
Academic metrics • GPA • Completion of specific prerequisites by application deadline • Additional degrees • Completion of chemistry
• • • • • • •
Commitment to Social Justice Oral Communication Written Communication Values that align with the profession Motivational fit for the profession Ability to tolerate stress Ability to learn from experiences
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
5
Fig. 1. Aggregate incoming class data on disadvantaged and underrepresented minority status in undergradaute programs.
•
•
changing perceptions and motivating faculty to learn more about applicants. Review incomplete applications for bias. Some disadvantaged students may not fully understand the importance of attending to details in their application, and as a result, their applications may be incomplete. For example, information regarding educational and economic disadvantage is collected via a supplemental, optional section. Some of the most disadvantaged students did not submit that portion of the application because it was optional. Instructions have been added to the application explaining the benefits of completing this supplemental section. Providing informational sessions on application completion is also a recommended practice. It's a journey. A key lesson learned is that the holistic admission process is a dynamic, iterative process so frequent evaluation of the process is recommended. For example, when we first added interviews, one question was developed for each station. Based on feedback from faculty, interviewers and experience with repeat applicants, a pool of questions for each station was developed by faculty and used statewide. Piloting new admissions practices was also found to be helpful prior to full implementation of a change. For example, one campus recently piloted adding diverse community partners to the admission review committee to identify strengths and challenges prior to full implementation. This pilot is in the process of being evaluated and shared with other programs.
Next steps With the full support of SON administration, faculty continue to reevaluate and update admission criteria based on evaluation of diversity goal attainment; there is still much work to do. Part of the iterative process includes determining the optimal balance of academic metrics and non-academic factors into admission decisions. Current admission practices are being compared to recommended best practices to identify gaps, such as focusing essay and interview questions more specifically on the OHSU SON mission and values; providing faculty development on unconscious bias; improving the reliability of admission rubrics; and, reconfiguring admissions committees. Holistic admissions best practices are currently being implemented throughout the SON, including in graduate programs. Ongoing evaluation of data includes determining which prospective students don't complete applications and comparing characteristics of both admitted and non-admitted students to identify disparities. A checklist of best practices has been developed for internal self-assessment by faculty admission committees (See Table 3). (American Association of Colleges of Nursing, 2016b; Association of American Medical Colleges, 2013; Glazer et al., 2015; Glazer et al., 2016; Scott & Zerwic, 2015; Urban Universities for Health, 2014).
Summary Data demonstrate that the SON has increased the number and percentage of underrepresented minority and disadvantaged students in undergraduate programs over the past 3 years. The diversity of undergraduate cohorts has increased with even modest changes in the admissions procedures. Holistic admissions is an important component of a diversity plan and is one element of a comprehensive plan of strategies to diversify the nursing workforce that must address recruitment, admission, retention, and graduation (Noone, Wros, Najjar, Cortez, & Magdaleno, 2016). Holistic admissions is a dynamic process to achieve Table 3 Holistic admissions checklist. Admissions mission School has an admissions mission statement that includes diversity. Selection criteria Selection criteria include an evidence-based balance of applicant experiences, attributes, and academic metrics. Selection criteria are linked to the university and SON mission/values. Initial screening includes evaluation of non-academic criteria (identify dimensions of diversity and disadvantage to be considered such as first generation college student, socioeconomic status, urban/rural community of origin, gender, race, foreign language ability). Selection criteria consider potential contributions to the learning community and the profession. The relative weight of each area (applicant experiences, attributes and academic metrics) is considered in contributing to the total score. Admissions committee The admissions committee is broadened to include diverse individuals. Admissions committee (reviewers, interviewers, and decision-makers) participate in unconscious bias training. Admissions process Essay questions address the school's mission and values. Essay questions are designed to identify students who are educationally or economically disadvantaged. Non-academic criteria are assessed after students have met the minimum criteria for admission. The admissions process includes interviews (group or individual). Essay and interview questions are standardized. A rubric is used to rate and document rankings on selection criteria. Admissions committees have the opportunity to discuss applicants. Admissions decisions include consideration of the overall diversity of the class. Students are selected from the waitlist by criteria related to the mission/values. Evaluation plan Evaluate demographics characteristics of students offered admission to those not to identify disparities. Regularly evaluate if outcomes are achieving SON admission mission and revise application process accordingly.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005
6
P. Wros, J. Noone / Journal of Professional Nursing xxx (2017) xxx–xxx
university and school missions, and represents a culture shift away from predominantly (or often exclusively) valuing academic metrics of student success to a balanced consideration of academic metrics, student attributes, and experiences that will contribute to the learning community and the nursing workforce. References Addams, A. N., Bletzinger, R. B., Sondheimer, H. M., White, S. E., & Johnson, L. M. (2010). Roadmap to diversity: Integrating holistic review practices into medical school admission processes. Washington, DC: American Association of Medical Colleges. American Association of Colleges of Nursing (2016a). Holistic admissions review in nursing. Retrieved from http://www.aacnnursing.org/Education-Resources/ToolKits/Holistic-Admissions-Tool-Kit . American Association of Colleges of Nursing (2016b). Holistic review: A quick primer. Retrieved from http://urbanuniversitiesforhealth.org/media/documents/Holistic_ Review_Primer.pdf. American Association of Colleges of Nursing (2016c). Holistic review in nursing — An introduction. [Video file]. Retrieved from https://www.youtube.com/watch?v= 0Zt_TfX7KoU&feature=youtu.be. American Association of Colleges of Nursing (2016d). Legal requirements for institutions using race and ethnicity-conscious policies. Retrieved from http:// urbanuniversitiesforhealth.org/media/documents/Legal_Requirements_for_ Institutions_Using_Race_and_Ethnicity-Conscious_Policies.pdf. American Association of Medical Colleges (2014). Advancing holistic review initiative. Retrieved from https://www.aamc.org/download/358384/data/holisticreviewbrochure. pdf. Association of American Medical Colleges (2013). Roadmap to excellence: Key concepts for evaluating the impact of medical school holistic admissions. Retrieved from https://members.aamc.org/eweb/upload/Holistic%20Review%202013.pdf. Felix, H., Laird, J., Ennulat, C., Donkers, K., Garrubba, C., Hawkins, S., & Hertweck, M. (2012). Holistic admissions process: An initiative to support diversity in medical education. Journal of Physician Assistant Education, 23(3), 21–27. Glazer, G., Clark, A., & Bankston, K. (2015). Legislative: From policy to practice: A case for holistic review diversifying the nursing workforce. Online J Issues Nurs, 20(3), 1. http://dx.doi.org/10.3912/OJIN.Vol20No03LegCol01. Glazer, G., Clark, A., Bankston, K., Danek, J., Fair, M., & Michaels, J. (2016). Holistic admissions in nursing: We can do this. J Prof Nurs, 32(4), 306-213. Goodfellow, A., Ulloa, J. G., Dowling, P. T., Talamantes, E., Chheda, S., Bone, C., & Moreno, G. (2016). Predictors of primary care physician practice location in underserved urban or rural areas in the United States: A systematic literature review. Acad Med, 91(9), 1313–1321. Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Hayes-Bautista, T. M., Schink, W., & Hayes-Bautista, D. E. (2016). Latino nurses in the United States: An overview of three decades (1980–2010). Am J Nurs, 116(2), 24–33. Komaromy, M., Grumback, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A. B. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med, 334(20), 1305–1310.
Marrast, L. M., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians' role in the care of underserved patients: Diversifying the physician workforce may be key in addressing health disparities. J Am Med Assoc, 174(2), 289–291. McMaster University (2017). Admission manual for reviewers. Retrieved from http:// mdprogram.mcmaster.ca/docs/default-source/admissions/interviewer-manualmmi_websiteversion.pdf?sfvrsn=2. Noone, J., Wros, P., Najjar, R., Cortez, D., & Magdaleno, L. (2016). Advancing health equity through student empowerment & professional success: A state-wide approach. J Nurs Educ, 55(6), 316–322. http://dx.doi.org/10.3928/01484834-20160516-03. Oregon Consortium for Nursing Education (2017). Welcome to the Oregon Consortium for Nursing Education (OCNE). Retrieved from www.ocne.org. Oregon Health Authority (2014). The Diversity of Oregon’'s Healthcare Workforce 2012—2013. http://www.oregon.gov/oha/HPA/ANALYTICS/HealthCareWorkforceReporting/20122013-Oregon%27s-health-care-workforce-diversity.pdf. Oregon Health & Science University (2013). OHSU diversity action plan 2013: Creating a community of diversity and inclusion. Retrieved from http://www.ohsu.edu/xd/ about/vision/center-for-diversity-inclusion/about/upload/OHSU_Diversity_Action_ Plan_2013.pdf. Oregon Health & Science University (2014). OHSU vision 2020 v. 2013: OHSU strategic plan 2013-2017. Retrieved from http://www.ohsu.edu/xd/about/vision/upload/ OHSU-Vision2020v2013for-Board-FINAL-Jan-30.pdf. Oregon Health Authority and Department of Human Services (2013). State of Equity Report Phase 2. http://www.oregon.gov/oha/oei/reports/State%20of%20Equity% 20Report%20-%20Phase%20II%20-%20September%202013.pdf. Saha, S., Taggart, S. H., Komaromy, M., & Bindman, A. B. (2000). Do patients choose physicians of their own race? Health Aff, 19(4), 76–83. Scott, L. D., & Zerwic, J. (2015). Holistic review in admissions: A strategy to diversify the nursing workforce. Nurs Outlook, 63, 488–495. Smedley, B. D., Stith Butler, A., & Bristow, L. R. (Eds.). (2004). In the nation's compelling interest: Ensuring diversity in the health-care workforce. Washington, DC: The National Academies Press. Terregino, C. A., McConnell, M., & Reiter, H. I. (2015). The effect of differential weighting of academics, experiences, and competencies measured by multiple mini interview (MMI) on race and ethnicity of cohorts accepted to one medical school. Acad Med, 90(12), 1651–1657. U.S. Department of Health and Human Services (2015). Sex, race and ethnic diversity of U. S. health occupations (2010− 2012). Retrieved from https://bhw.hrsa.gov/sites/ default/files/bhw/nchwa/diversityushealthoccupations.pdf. Urban Universities for Health (2014). Holistic admissions in the health professions: Findings from a national survey. Retrieved from http://urbanuniversitiesforhealth.org/ media/documents/holisticadmissionsinthehealthprofessions.pdf. Wells, A., Brunson, D., Sinkford, J. C., & Valachovic, R. W. (2011). Working with dental school admissions committees to enroll a more diverse student body. J Dent Educ, 75(5), 685–695. Wilson, M. B., Sedlacek, W. E., & Lowery, B. L. (2014). An approach to using noncognitive variables in dental school admissions. J Dent Educ, 78(4), 567–574. Witzburg, R. A., & Sondheimer, H. M. (2013). Holistic review—Shaping the medical profession one applicant at a time. N Engl J Med, 368(17), 1565–1567. Xue, Y., & Brewer, C. (2014). Racial and ethnic diversity of the U.S. national nurse workforce 1988–2013. Policy, Politics and Nursing Practice, 15(3/4), 102–110.
Please cite this article as: Wros, P., & Noone, J., Holistic admissions in undergraduate nursing: One school's journey and lessons learned, Journal of Professional Nursing (2017), http://dx.doi.org/10.1016/j.profnurs.2017.08.005