To address health inequities in the United States, the American Association of Colleges of Nursing, Robert Wood Johnson Foundation, and the Institute of Medicine recommend increased representation of Black and other underserved populations in the health professions. Black nurses are more likely to work in underserved communities, but due to multiple barriers in our current admissions processes, Black students’ have limited access to RN education.

The majority of U.S. Registered Nurse (RN) graduates train in associate and bachelor’s degree programs. They apply first to the academic institution, complete prerequisite courses, and apply to the nursing program one or more years later. However, in a study of almost 2,500 pre-nursing students, only 44 of 252 Black students submitted a nursing application, with the majority withdrawing after freshman-level anatomy and physiology.

I have 28 years of experience as a professional nurse and 17 years in academia, yet my 3.3 high school grade point average (GPA) and 1,100 SAT score would have precluded my admission to most nursing programs. I was able to enter the field through an alternate pathway, the accelerated Master’s entry program in nursing at UC San Francisco, a program for students with bachelor’s degrees in other fields. Without this pathway and the use of holistic admissions review (HAR), I would not be a RN today.

HAR is one strategy to increase admission of Black students because it features the balanced use of academic metrics (e.g, GPA and standardized test scores), personal characteristics, and experiences in admissions selection. This is critical because academic metrics are significantly influenced by racial bias and economic privilege. According to a 2014 survey, a majority of dental (93%), medical (91%), and pharmacy (78%) programs embraced HAR in their admissions policies. However, only 47% of nursing programs used HAR. In 2021, 50% of nursing programs still relied exclusively on academic criteria for admissions. Several misconceptions sustain the admissions status quo in nursing education.

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Misconception 1: “Black students are not interested in nursing.”

Reality: Thirty-two percent of nursing assistants and 23% of licensed vocational nurses are Black, far exceeding the representation in the general population (13%). Highly selective admissions criteria in colleges and universities could disqualify interested applicants before or during the admissions process. Black students, who are more likely to be educated in segregated and underfunded schools, might be overlooked in admissions screening due to lower test scores and grades. Additionally, health and liability insurance requirements can deter students who lack financial resources.

Misconception 2: “GPA and test score ranking is the most fair and efficient way to make admissions decisions.”

Reality: Academic metric-driven admissions are the fastest method, but not the most equitable. Compared to White and higher-income applicants, Black students’ perceived and actual performance is negatively affected by grading bias (elementary and higher education), disproportionate school suspension rates, arrests, and limited tutoring and test preparation access. In addition, they typically work more than their counterparts leaving less time for studying and test preparation.

Misconception 3: “Academic support services must be established before admitting Black students.”

Reality: The admission of Black students is not equivalent to admitting unqualified students. Programs that implemented HAR reported unchanged or increased GPAs, graduation, and licensure pass rates. However, Black students could benefit from university services such as summer bridge, academic advising, counseling, and financial aid programs to address non-academic stressors (because income is a predictor of nursing program success). Nursing programs can also work to promote a sense of belonging and engagement to boost performance without increasing resource demands.

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Misconception 4: “Students admitted using lowered admission standards will fail licensure exams.”

Reality: The admission of qualified Black students is not equivalent to lowered admission standards. More Black students might qualify for admission if programs used HAR for the selection process. Graduation and licensure pass rates are associated with science GPA and standardized nursing tests (TEAS), but not overall GPA (most common). Additionally, there is no evidence to suggest that a student with a 3.5 GPA and a 58 test score is less likely to succeed than one with a 4.0 and 85.

Misconception 5: It is illegal to consider race in admissions.

Reality: Since the 1996 ban on Affirmative Action, academic institutions successfully defended their use of race as a mission-aligned component of admissions policies in 3 Supreme Court cases. HAR is one of few evidence-based approaches to increase student diversity in health professional education programs.

Without targeted efforts to increase Black student enrollment, highly selective admissions policies will continue to present access barriers for qualified students in nursing. The American Association of Colleges of Nursing and the Association of American Medical Colleges published guides for HAR implementation, yet, the majority of nursing programs rely solely on academic metric criteria for admissions even though qualified Black students are disadvantaged by them. The original purpose of GPA and standardized test use in U.S. higher education was to segregate White American students from immigrants and Black students. Their use in 2022 as a standard of admissions policy continues to restrict Black student access to nursing education, as evidenced by the fact that 74% of the RN workforce, health care’s largest sector, identify as White. In order to facilitate diverse workforce development that enhances health and education equity, exclusionary college admissions policies must be replaced with HAR.

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Michelle DeCoux Hampton, PhD, RN
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