Holistic Review Impacts Success of Underrepresented Minority Nursing Students: A Case Study

Sunday, 30 July 2017

Joana Velasquez, MS
Carleen Graham, MSN
Sandra Ellen Bell, MSN/Ed
Phillips School of Nursing at Mount Sinai Beth Israel, New York, NY, USA

Purpose:  The purpose of this project is to increase the enrollment, retention, and graduation of individuals from disadvantaged backgrounds, including ethnic and racial minorities, in the accelerated Associate's Degree in Nursing (aADN) program at the Phillips School of Nursing at Mount Sinai Beth Israel (PSoN).

Our target populations for this initiative reflect the demographics of the five boroughs of New York City (NYC), the most populous city in the US (NYC Planning, 2014) as well as disparity in the nursing workforce in our region: 1) Latinos; 2) blacks; 3) individuals who are economically disadvantaged; and 4) individuals who are educationally disadvantaged. As the demographic data demonstrates, these populations often overlap. Hence, we anticipate that the majority of applicants identified as racial/ethnic minorities may also be economically and/or educationally disadvantaged.

Background and Significance: The nursing profession has been working towards increasing the diversity of nursing students in an attempt to keep up with changing demographics and complex healthcare systems. It is projected that racial and ethnic minorities will comprise more than half of the US population in the next 20 years; however, this prevalence is not reflected in nursing education or practice (Scott & Zerwic, 2015).

In the American Association of Colleges of Nursing (AACN) report (2016), it was noted that there was an increase in enrollment of ethnic minority groups in generic (entry-level) baccalaureate programs from 25.2% in 2006 to 31.6% in 2015. Nonetheless, recruiting and retaining more minority nurses still remains as an objective of nursing education. Nursing programs could facilitate increased minority representation in the nursing workforce by increasing recruitment and improving retention of minority nursing students (Loftin, Newman, Dumas, Gilden & Bond, 2012). Anecdotally speaking, faculty and administration have come to the realization that diversity in the classroom goes beyond ethnicity and race, and, are further realizing that this increase in diversity is also associated with many socio-cultural issues.

Culturally diverse nursing students are considered a vulnerable population due to social isolation and lack of faculty support and supportive services (Muronda, 2015). According to Degazon and Mancha (2012), the benefits of having a diverse student body are twofold: it will increase the likelihood that patients from diverse backgrounds will receive culturally congruent care and it will contribute to the development of more effective health policies. Consequently, a diverse nursing workforce will lead to narrowing of disparities in health outcomes. Numerous studies had been conducted to explore barriers and facilitators to success of minority nursing students (Loftin, Newman, Dumas, Gilden & Bond, 2012; Tabi, Thornton, Garno & Rushing, 2013). Similarly, best practices to attract and retain minority nursing students had been reviewed (Condon, Morgan, Miller, Mamier, Zimmerman & Mazhar, 2013; Dapremont, 2013; Carthon, Nguyen, Chittams, Park & Guevara, 2014).

Scott and Zerwic (2015) proposed that another strategy that can be used to diversify the nursing students is through the use of holistic admissions review. Holistic review, as described by the American Association of Medical Colleges (AAMC), is “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes and academic metrics and, when considered in combination, how the individual might contribute value as a medical and future physician” (Addams, Bletzinger, Sondheimer, White & Johnson, 2010, p. 10). While a few nursing schools have started implementing the use of holistic review as part of the admission process, there is a gap in the current literature on using holistic review as part of the academic progression of students throughout the program.

Methods:  An innovative program initiative at PSoN has been a program of support for returning students. Few schools of nursing permit students who have dropped out to return. Given the barriers and challenges minority students in particular face, we realize that many students drop out due to unanticipated personal or family circumstances, work obligations, or financial challenges.

PSoN will implement a holistic review admissions process that comprises the four basic principles of holistic review: 1) alignment with our School’s mission and goals; 2) assessment of applicants’ experiences, attributes, and academic metrics in the context of social determinants; 3) individualized consideration; and 4) consideration of race and ethnicity as factors in the selection of students for admission to the aADN program.

We will adjust the current admission rubric to reflect a new scale of assessment for the pre-admission test, define with greater precision and clarity factors that may constitute non-academic criteria, redesign the application form and personal interview questions/guidelines to capture this information, as legal and appropriate, and broaden the scope of personal essay questions. In order to create a new rubric, we will review models developed by schools of nursing currently employing a holistic review process.

During the admission process, applicants who were previously enrolled in a nursing program but were unsuccessful and consider themselves as part of underrepresented minority (URM) will be identified. The project will be explained to the potential candidates and consent to participate will be obtained. A case study following the students from admission to graduation from the program will be conducted highlighting how holistic review was used throughout their academic progression.

To support a systematic, integrated, and consistent holistic review process we will create a Holistic Review Toolkit, based on current best practices (Glazer, 2016), which will include: a) rationale; b) goals and objectives; c) legal issues; d) an overview of the holistic review process; e) copies of the new application forms; f) new rubric(s); g) information on non-academic criteria; h) guidelines for personal interviews; and i) expected outcomes. Non-academic criteria may include: race/ethnicity; community of origin; first generation college student; languages spoken and level of proficiency; socioeconomic status; work status; quality and rigor of prior educational experience; breadth of the applicant’s prior education, training, and experience; competence in non-traditional areas of learning; academic achievement within the context of non-academic challenges; significant personal challenges; and leadership experience.

Holistic review will also be used in following the participants’ progression in the program. Final course grades, interactions with faculty, staff and peers, professionalism, as well as participation in extracurricular activities will be reviewed and documented. The Grants and Scholarships Committee will award the participants with partial scholarships and stipends. A reduction in the cost of tuition in combination with funds for basic living expenses will provide a substantive source of support for students in the initiative’s target populations. Peer mentoring, Career Development and Readiness Program (i.e., boot camp) and enhanced tutoring services will be made available to the students.

Our long-term goal is to contribute to the development of a highly skilled, adept, and adaptable workforce that reflects, and is prepared to serve, the most diverse urban communities in the country, the residents of NYC. Additionally, we aim to support URM nursing students at PSoN throughout the entire educational pipeline, from enrollment through graduation, to become registered nurses (RNs) and find employment in our region.

Results:  Based on the assumptions, as outlined in the Logic Model and the specific interventions we have designed to achieve our goals and objectives, we expect the initiative to result in the following outcomes: 1) Enrollment of students in the target populations will increase by 10%; 2) 100% of the participants will complete the program within 15 months of enrollment; 3) students’ licensure first-time pass rate will be at or above the state and national means; 4) At least 85% of the scholarship recipients who do not enroll in the RN-BSN program will obtain employment within 12 months following RN licensure; 5) At least 90% of the participants will be satisfied with the education they received; 6) PSoN retention rates will improve by a minimum of 5% for the target populations; 7) PSoN graduation rates will improve by a minimum of 5% for students in the target population; 8) At least one student in the cohort will enroll in the RN-BSN program following licensure.

Conclusion:  Fostering a culture of diversity and inclusion is integral to our School’s mission, vision, and philosophy, and aligns with our academic approach. Every course in the curriculum includes an objective related to the development of cultural competency and students are evaluated on their ability to communicate in a culturally sensitive manner and to deliver culturally-competent patient care. Creating a nursing workforce that reflects the city’s unusually diverse population and is adept at inter-cultural communication and prepared to provide culturally sensitive and competent care will be critical to meeting the city’s changing and increasingly complex healthcare needs.

Nursing educators are at a unique vantage point of influencing global health. Educators are able to design curricula that strengthen the teaching of health policy development, thereby, increasing nursing presence in policymaking. According to CDC, as described by Shishani, Allen, Shubnikov., Salman, LaPorte, & Linkov (2012), global/public health is not routinely taught in nursing schools; however, most nurses have basic knowledge of disease prevention strategies, which can be harnessed to improve global health . Educators can provide nursing students with introductory concepts that support global health work that transcends borders.