Failing the Profession

Reliance on academic merit for admission selection at nursing schools has led to disparities in health care for underserved communities. Using standardized test scores, grade point average and grades earned in science courses, without consideration of life experiences and attributes, has limited racial and cultural diversity among nursing school applicants. Students who attend less rigorous high schools than their peers and are unable to afford test-preparation materials are less likely to apply. Academic-centric admissions is often intimidating for students who were not provided with the same educational opportunities as their peers, even if their disposition and background experiences lend themselves to nursing.

The lack of racial and cultural diversity found in nursing schools eventually leads to limited access to health care for disadvantaged populations. Nurses from diverse backgrounds are more inclined to work with patients in underserved areas. Without a diverse workforce, many patients living in underserved communities receive lower standards of care and inadequate services. The care patients receive is often tied to socioeconomic status, race, education and living conditions. Health care inequities of this kind recently came to light during the COVID-19 pandemic, as many underserved communities reported higher infection rates and less access to vaccinations. Patient outcomes improve when they are cared for by nurses of the same race, ethnicity or social status due to a higher level of trust between nurse and patient.

How a nursing school determines the type of student it wishes to admit should be informed by the needs of the profession, rather than biased admission practices.

In the United States, only 19 percent of nurses are considered nonwhite. That percentage is lower still for nurses in leadership roles. In 2016, the American Association of the Colleges of Nursing (AACN) began promoting a holistic admission review process to align with the growing need for racially and culturally diverse nurses in health-care systems. Holistic admission review considers the experiences and intrinsic attributes of applicants in addition to their academic merit. It provides nursing schools the opportunity to evaluate qualities like caring, compassion and persistence as well as an applicant’s experiences relevant to nursing. Nursing schools utilizing holistic admission review are able to tailor their requirements to evaluate how a potential student will contribute to both the school and the field of nursing.

Interviews, written applications, essays and tools such as the Jefferson Scale of Empathy are some of the methods AACN and other advocates have suggested for implementing a holistic process. Interviews, in particular, have proven to be quite effective in increasing racial and cultural diversity. Applicants have reported feeling more comfortable sharing their diverse backgrounds, experiences and abilities through this format. Nursing schools that have employed holistic admission review have seen a significant increase in the number of diverse applicants without any changes to overall GPA, science grades or test scores.

In spite of its proven effectiveness, holistic admission practices can be challenging. They require complete buy-in from school administration and faculty, who historically have remained silent on the inherent bias norms of the profession. Holistic admission review has been utilized by dentistry, public health, pharmacy and medical schools at much higher percentages than nursing schools. As a direct result, those fields have reported an increase of over 70 percent in student body diversity as well as an openness of students to consider perspectives different from their own. As students work alongside one another, sharing experiences and voicing concerns, they are more apt to understand the value of diversity in nursing.

Holistic admissions at the graduate level is particularly imperative to curtail disparities in health care. Systemic injustices in nursing have created myriad barriers to pursing graduate-level programs, leadership roles and opportunities for research for minoritized populations. Many Black and Hispanic nurses have experienced racist attitudes and behaviors in the workplace from fellow and supervising nurses. They have reported being denied requests for professional development and promotions because their nursing manager felt they were not as capable as their white counterparts.

A financial impact survey of over 10,000 nurses taken by the American Nursing Foundation in July of 2020 inadvertently showed that Black, Hispanic and Latino nurses were more likely to work in roles having direct contact with COVID-19 patients and were twice as likely to be diagnosed with the virus than their peers. The lack of diversity among nursing leadership has led to less advocacy for policies that improve health care for underserved populations and address discriminatory issues within the nursing profession.

A holistic approach to admissions in nursing schools is a race-conscious perspective allowing race to considered along with experiences, attributes and academic merit to increase diversity. Working to redress a denial of opportunities in nursing that has occurred and continues to occur due to race and ethnicity requires an acknowledgment of the problem at the highest level and an appreciation for the value increased diversity brings to the profession. Holistic admission practices on their own may not be enough to redress the historically, systemically discriminatory structure of nursing, but it is a concrete measure nursing schools can use now to encourage diversity, mitigate implicit bias and prepare to tackle issues in health care faced by underserved communities.