Journal of Nursing Education

Educational Innovations 

A Practical Guide for Implementing a Holistic Admissions Review

Lisa Rosenberg, PhD, RN

Abstract

Background:

Various minorities in terms of race, ethnicity, gender, sexual identity, and socioeconomic status experience poorer health outcomes than those in the majority. Evidence indicates that provider diversity is associated with improved access to care for minorities, increased patient satisfaction, improved outcomes, and better educational experiences for health professions students.

Method:

The holistic admissions review is a flexible, individualized way of assessing an applicant's capabilities through consideration of experiences, attributes, and metrics (EAMs) that can serve as an important tool in diversifying the nursing workforce.

Results:

This article discusses (a) critical elements that must be addressed during the development and implementation of a holistic admissions review and (b) the creation and use of a scoring rubric based on the EAMs identified.

Conclusion:

The implementation of a rubric was found to be a helpful tool to create a more thoughtful review of noncognitive factors and greater diversity in the student body. [J Nurs Educ. 2019;58(11):669–673.]

Abstract

Background:

Various minorities in terms of race, ethnicity, gender, sexual identity, and socioeconomic status experience poorer health outcomes than those in the majority. Evidence indicates that provider diversity is associated with improved access to care for minorities, increased patient satisfaction, improved outcomes, and better educational experiences for health professions students.

Method:

The holistic admissions review is a flexible, individualized way of assessing an applicant's capabilities through consideration of experiences, attributes, and metrics (EAMs) that can serve as an important tool in diversifying the nursing workforce.

Results:

This article discusses (a) critical elements that must be addressed during the development and implementation of a holistic admissions review and (b) the creation and use of a scoring rubric based on the EAMs identified.

Conclusion:

The implementation of a rubric was found to be a helpful tool to create a more thoughtful review of noncognitive factors and greater diversity in the student body. [J Nurs Educ. 2019;58(11):669–673.]

Health care workforce diversity has been recognized as an important factor in improving health outcomes for the broad spectrum of patients and populations in the United States. Various minorities in terms of race, ethnicity, gender, sexual identity, and socioeconomic status experience worse health outcomes than those in the majority (Agency for Healthcare Research and Quality, 2017; Centers for Disease Control and Prevention, 2011; Noonan, Velasco-Mondragon, & Wagner, 2016; Smedley, Stith, & Nelson, 2003; U.S. Department of Health and Human Services, 2011). Evidence indicates that provider diversity is associated with improved access to care for racial and ethnic minority patients, increased patient satisfaction with the care experience, improved patient outcomes, and better educational experiences for health professions students (Addams, Bletzinger, Sondheimer, White, & Johnson, 2010; LaVeist & Pierre, 2014; U.S. Department of Health and Human Services, 2006; Valantine & Collins, 2015). Holistic admissions diversity initiatives have demonstrated their value in creating a qualified and more diverse health care workforce (Urban Universities for Health, 2014). The purpose of this article is to provide a practical and systematic approach to the development and implementation of a holistic admissions review.

Momentum has been building for schools of nursing to incorporate some form of holistic admissions over the past several years. The holistic admissions review process is described by the Association of American Medical Colleges as “a flexible, individualized way of assessing an applicant's capabilities by which balanced consideration is given to experiences, attributes, and academic metrics” (Addams et al., 2010, p. 10). This definition has been widely adopted by other health professions, including nursing, and medicine and dentistry have been early and robust adopters of the holistic review. Data from the Holistic Admissions in the Health Professions: Findings From a National Survey (Urban Universities for Health, 2014) found that as student diversity increased in schools reporting use of holistic review practices, measures of student success (academic performance and retention) were either unchanged or improved.

Method

Foundational Elements for a Holistic Admissions Process

The Association of American Medical Colleges' Roadmap to Diversity (Addams et al., 2010) laid the early groundwork for consideration of the development and implementation of a holistic admissions process. Others (Artinian et al., 2017; DeWitty, 2018; Glazer et al., 2016; Glazer, Tobias, & Mentzel, 2018; Grabowski, 2018; Scott & Zerwic, 2015; Wros & Noone, 2018) have subsequently provided informative discourse on the development and use of a holistic admissions review. When first considering a holistic admissions initiative, several critical foundational elements must be addressed prior to the development and implementation of a holistic admissions review process. These substantial issues are outlined below.

Express Value of Diversity in Organizational/College Mission, Vision, and Strategic Goals. A diversity initiative must be mission-driven, with language and activities embedded throughout the organization that reflect diversity as an important element for institutional excellence (Addams et al., 2010). According to Rosenberg and O'Rourke (2011):

Creating a culture of inclusion underlies any effort to promote diversity, and explicit demonstrations of these efforts must be apparent. For example, organizational mission, vision and value statements; university, school and department strategic plans; faculty, staff, and student development activities are fundamental vehicles whereby the words and actions of diversity are infused into the culture and functioning of the institution.

Solidify Stakeholder Buy-In at All Levels. Administration, faculty, and admissions staff need to demonstrate a solid commitment to enhancing diversity in the nursing workforce—the use of a holistic admissions process is an important step in achieving this outcome. Stakeholder involvement during the planning, implementation, and evaluation stages of the process is essential—otherwise the likelihood of success is greatly diminished. The architect Cameron Sinclair said, “A true architect is not an artist but an optimistic realist. They take a diverse number of stakeholders, extract needs, concerns, and dreams, then [together] create a beautiful yet tangible solution that is loved by the users and community at large” (Center for Health Innovation and Implementation Science, 2018).

Corollary to Stakeholder Buy-In. Address the issue of faculty time in doing a holistic admissions review. Faculty workload is a frequent topic of conversation when any change in a critical process, such as admissions, is suggested (Glazer et al., 2016). A faculty and staff that believe in the importance of a diversified nursing workforce will be more fully engaged in learning to use the tools of holistic admissions. Although additional faculty time may be required, for example, to conduct applicant interviews, it has been our experience that faculty enjoy the personal nature of these interactions with applicants and their contribution to the shaping of the incoming class.

Define the Experiences, Attributes, and Metrics That Comprise Your Holistic Review. There must be a common, agreed upon understanding of which noncognitive variables are important in providing the diversity sought in the student body. There is not only one preferred way to understand these variables. One school may value students who are bilingual, whereas another may place greater significance on leadership experience. Whatever the set of experiences, attributes, and metrics may be, each school must determine what those variables are and then have the ability to measure them during the application process (Association of American Medical Colleges, 2014).

Implement the Modalities in the Application Process to Collect Data on the Desired Noncognitive and Cognitive Variables. This may take the form of a requesting a curriculum vitae (CV) or resume, essay statement, and recommendations, conducting an interview with the applicant, or collecting specific grade point average (GPA) or standardized test scores (Wilson, Sedlacek, & Lowery, 2014).

Recruit a Large Enough Pool of Qualified, Diverse Applicants. A school's definition of diversity will direct their recruitment priorities (Rosenberg & O'Rourke, 2011). For example, a school may decide that they wish to increase the number of Hispanic students based on a growing Hispanic population in their state. In any of the conversations and articles about using a holistic admissions review, it is assumed that a school can use a holistic process because they have a pool of qualified, diverse applicants from which to choose. Using the above example, if a school wished to mirror their state in the percentage of Hispanic students accepted, they would need greater than that number of Hispanic applicants (by at least 25%) in their pool. If that is not the case, then implementing a holistic review may be premature. An applicant pool that is not diverse—as defined by the school—will require different recruitment tactics to make a holistic review meaningful.

Create the Metric Floor. This may be the most critical paradigm shift in thinking that must occur. Schools need to establish not the usual metric ceiling but the metric floor (e.g., GPA, standardized test scores) that is essential to academic success. It means moving away from the priority of high metrics as the most important selection criteria to a more balanced consideration of metrics, experiences, and attributes in choosing who will be successful in nursing and what value they bring to the profession (Scott & Zerwic, 2015). Even after consideration and collection of applicant noncognitive variables, there is still a risk of falling into old admissions committee review habits, such as using a spreadsheet that presents candidates from highest to lowest GPA. The use of a scoring rubric that incorporates ratings on a variety of cognitive and noncognitive factors should ultimately enhance student retention, as metrics alone will never account for the characteristics necessary for success as a health professional.

Defining Your EAM (Experiences, Attributes, and Metrics) Model

It should be noted at this point that establishing the above critical, foundational elements is where the hard work lies on the path to creating a robust holistic admissions review process. After key stakeholders have identified the important experiences, attributes, and metrics desired in the student body, each EAM must have a descriptor that defines how the applicant meets expectations (Vick et al., 2018). Some experiences and attributes have descriptions of varying levels of performance (e.g., exceeds, meets, and below standard) so faculty have a common guide when reviewing an application. Other EAMs are more straightforward in that the applicant either does or does not demonstrate the desired element. After these descriptors are developed, sessions must be held with faculty to explain each variable and where to find the information in the application. Table 1 provides some of the EAMs with corresponding scoring descriptors chosen by one midwestern college of nursing for their direct-entry master's program.

Sample of Experiences, Attributes, and Metrics With Descriptors

Table 1:

Sample of Experiences, Attributes, and Metrics With Descriptors

NursingCAS Scoring Rubric

In order for these variables to be evaluated across candidates, a scoring rubric was developed to express a numerical range for each identified metric, attribute, and experience. The scoring rubric was created within the admissions platform, NursingCAS—the centralized application system endorsed by the American Association of College of Nursing. WebAdmit™ is a part of the admissions software that allows staff to manage and faculty to review and evaluate the applicant pool in NursingCAS. The school has the ability to create a scoring rubric that will populate in each application. Some of the categories for scoring can be generated automatically—for example, cumulative GPA. Other categories require manual entry and have appropriate response drop-down menus (e.g., yes or no for military experience; exceeds, meets, or is below expectations for languages spoken). Numerical scores are created for each answer (e.g., 1 = military experience, 0 = none; 2 to 0 range = languages spoken). A total of 17 factors were identified, five of which are generated automatically and 12 scored manually (Table 2). After the rubric is completed for a candidate, a total score is created. Applicants have the ability to earn a total of 32 points. Metrics, experiences, and attributes each respectively contribute approximately one third to the total points, thus providing a more balanced overall scoring profile.

Scored Experiences, Attributes, and Metrics

Table 2:

Scored Experiences, Attributes, and Metrics

One important method for assessing an applicant's attributes and experiences is the personal interview. There is much evidence in the literature (House, Sturgeon, Garrett-Wright, & Blackburn, 2015; Knorr & Hissbach, 2014; Roach et al., 2019; Rosenberg, Perraud, & Willis, 2007; Wilson et al., 2014) to support the use of interviews for making holistic admissions decisions, as well as a number of different methods used by schools to interview applicants (e.g., one-to-one, group, multiple mini interviews, video interviews).This article is not meant to discuss or favor one method versus another.

The nursing program referenced in this article uses individual, 30-minute interviews that follow a set interview guide. It is important to note that the interview rating is considered separately from the rubric in making admissions decisions. With the experience of interviewing comes the knowledge that what is on paper does not always match reality. The interview is a venue in which the interviewer can confirm that the candidate is mature, understands the work of nursing and the rigors of the program, and has a caring attitude toward other human beings and the flexibility and perseverance to be successful. It can also help uncover those candidates that are overtly ill prepared or ill equipped for nursing school or the nursing profession. Should that be the case, the interview can be considered separately as a reason to deny admission.

Results

Each of a school's diligent efforts to define EAMs and implement methods to collect and evaluate that information can go awry, depending on how the applicant data are displayed and reviewed in the final selection process. Many schools with larger target enrollments will display summarizing candidate information on a spreadsheet. Viewing applicants sorted by high to low GPA can be avoided when another composite, holistic measure is available where metrics are part of the story, but other attributes and experiences broaden the consideration.

The annual targeted prelicensure enrollment for the college was 152 students: 76 enrolled in the spring and fall terms, respectively. Prior to spring 2018, a form of holistic admissions was in place that used a rated interview based on noncognitive factors, completion of an essay, submission of three recommendations, and a résumé. In spring 2018, the holistic scoring rubric was added. The spreadsheet(s) reviewed by the selection committee contained several fields of information including narrative interviewer comments, but the applicants were displayed from high to low according to holistic rubric scores.

Table 3 delineates the underrepresented minority, prelicensure students accepted for each cohort beginning fall 2016 and ending spring 2019. For the fall 2016 through fall 2017 cohorts, prior to the rubric being fully implemented the average percentage of accepted underrepresented minority students was 25.22%. From spring 2018, when we began using the holistic admissions rubric, through the spring 2019 cohort the average percentage of accepted underrepresented minority students was 32%.

Percentage of Underrepresented Minoritya Prelicensure Students Accepted Per Cohort

Table 3:

Percentage of Underrepresented Minority Prelicensure Students Accepted Per Cohort

It is worth noting that in fall 2017 and spring 2018, a decrease occurred in both overall and diverse applicants. In fall 2018, an adjustment was made to the cumulative GPA needed (3.0) for a Graduate Record Examination (GRE) waiver, bringing our requirement in line with other schools that use the GRE. We believe that this change was largely responsible for increasing the overall size of the applicant pool and the percentage of diverse students applying. The larger pool of applicants allowed us to accept an increased numbers of qualified and diverse students in fall 2018 and spring 2019. The average cumulative GPA of accepted students remained the same before and after the GRE waiver modification.

In these postrubric cohorts, all newly accepted students were in the high (32 to 21) or medium (20 to 10) range of rubric scores. Considering applicants in categories of high, medium, and low holistic categories, as opposed to making decisions based on singular point totals, takes into account the potential differences in perception across and among faculty raters over time. Admissions decisions are not an exact science and a rigid adherence to point totals is a false prophesy of prospective student success.

None of the student cohorts who were admitted using the holistic admissions rubric have yet to graduate and take the NCLEX. What can be reported is that the college's NCLEX pass rate for 2015 to 2018 averaged 97% with the holistic admissions process in place prior to spring 2018 (using an interview, recommendations, essay, and CV as part of the decision-making process). The college's student attrition rate pre- and post-rubric implementation has remained steady at 1.5% to 2%.

Challenges that exist with an ongoing holistic admissions process are to provide continuing diversity and inclusion education and holistic admissions training for both current and new faculty and staff. Periodic assessment of the process against indicators of student success, faculty feedback, and rubric evaluation should also be performed. Human and capital resources to perform these activities each year must be considered.

Conclusion

This article is meant to provide a practical guide to the development of a holistic admissions review. The implementation of a rubric is a helpful tool to codify institutional thinking, generate more consistent input across faculty, and create a more thoughtful review of noncognitive factors. However, the hardest work comes well before that point in the cultural paradigm shift that may need to occur in what factors we value and measure in our applicants. This is a long-term process that requires commitment from a variety of stakeholders. However, the impact of diversifying the nursing workforce on the health outcomes of an increasingly diverse U.S. population is significant and well worth our efforts to actualize.

References

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Sample of Experiences, Attributes, and Metrics With Descriptors

EAMsExceeds StandardMeets StandardBelow Standard
Grade trendsaConsistent high-performance in years 1 to 4 of collegeSome variability in performance (particularly year 1)Poorer grades seen spread over years 1 to 4
Languages spokenaFluent or proficient in a second languageLimited proficiency in a second languageNot proficient in a second language
Focus on underserved populationaHas significant previous work or community service experience with underserved populations and indicates desire to continue working with these populationsAt least one experience with underserved populations through work or community serviceNo experience with underserved populations
Active military or VeteranbYes
Prerequisite GPAb3.5 or greater

Scored Experiences, Attributes, and Metrics

Automatically Scored Items
Prerequisite course GPA
Science GPA
Cumulative GPA
Science hours
Graduate record examinations (scores or waived)

Manually Scored Items

Underrepresented in nursinga
Graduate degree
Military/Veteran
Leadership roles
Perseverance or “distance travelled”
Language skills
Health care/community service experience
Focus on underserved populations
Written communication
Cocurricular involvement
Professional attributes, (i.e., integrity)
Grade trend

Percentage of Underrepresented Minoritya Prelicensure Students Accepted Per Cohort

Fall 2016Spring 2017Fall 2017Spring 2018Fall 2018Spring 2019
24.2431.6419.7919.0438.2038.63
Authors

Dr. Rosenberg is Associate Dean Emeritus, Rush University College of Nursing, Chicago, Illinois.

The author has disclosed no potential conflicts of interest, financial or otherwise.

The author thanks Jennifer Thorndyke, MPH, and Molly Spurlock, MM, for their assistance during this project.

Address correspondence to Lisa Rosenberg, PhD, RN, Associate Dean Emeritus, Rush University College of Nursing, 600 S. Paulina St., Suite 1080, Chicago, IL 60012; e-mail: lisa_rosenberg@rush.edu.

Received: April 11, 2019
Accepted: July 24, 2019

10.3928/01484834-20191021-11

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