Standardized Tests: A Failing Grade for Diversifying the Healthcare Workforce
Members of the Jegna Council have developed pieces to highlight areas of their work that intersect with the Foundation’s priorities in New Jersey. Each of the articles reflect members’ thoughts on different areas that contribute to health inequities and ways that we can create a more equitable healthcare workforce, expand housing options, expand community research, and improve maternal health outcomes.
The following article was authored by Jegna Council Members Linda Sloan Locke, CNM, MPH, LSW, FACNM, founding chair of the New Jersey Health Cares about Domestic and Sexual Violence Collaborative, and Dr. Nastassia Davis, DNP, MSN, RN IBCLC, founding president of the Perinatal Health Equity Foundation.
An Introduction by Maisha Simmons
Building a Culture of Health in New Jersey requires policies that center health and racial equity in our state’s practices and systems by addressing obstacles that threaten wellbeing and prosperity for many people of color. Below, Linda Locke and Nastassia Harris explore the ways that racial inequities cause inadequate representation in the healthcare workforce and across the medical field. The authors uncover racial biases inherent in healthcare policies, practices, and procedures. They make it clear that equity in healthcare cannot be achieved without addressing structural issues that erect barriers to people having the opportunity to live their healthiest lives.
Maisha Simmons, RWJF senior director of New Jersey Grantmaking
A diverse healthcare workforce not only advances the essential goal of social equity, but it also paves a path towards a healthier population. Research tells us that race often influences diagnostic and treatment decisions, and Black patients are better able to communicate with physicians who are Black. We know, too, that patient satisfaction, access to care, and health outcomes improve when patients have access to culturally concordant providers.
Yet White clinicians dominate virtually every healthcare profession. Just 5 percent of practicing physicians and about 7 percent of nurses identify as Black or African American. Given the tragically high rates of maternal mortality in this population, disparities in the fields of obstetrics and gynecology are particularly concerning. The percentage of Black residents in obstetrics and gynecology has declined in recent years, falling to 8 percent in 2019. Only 7 percent of certified nurse midwives or certified midwives are Black, yet Black women represent 16% of those giving birth. People of color are also sparse in dental, pharmacy, physician assistant, and physical therapy positions. We urgently need more Black and Brown healthcare workers.
The inequities have their roots in underfunded public schools, underinvested neighborhoods, lack of economic opportunity, and the structural racism that underpins these and so many other social determinants of health. When the Urban Institute looked specifically at recruiting and retaining nurses of color at every educational level, researchers identified obstacles that included an absence of role models and mentors, inadequate structured support and financial assistance, and institutional environments that have not fostered inclusive cultures.
All of these obstacles can negatively influence performance on standardized tests and other measures of academic achievement, which are a major factor in determining who is admitted to professional schools in the healthcare field, and ultimately who is licensed to practice. An unyielding emphasis on test scores and grade point averages ignores biases that have long advantaged privileged students. Equally important, they fail to consider many of the skills that make applicants more effective clinicians. As authors asserted in the American Medical Association’s Journal of Ethics, “an applicant’s facility with collaboration, conscientious approach to problem solving, and grit might be traits more reliably indicative of undergraduate medical, residency, or professional success than MCAT [Medical College Admission Test] scores.”
Students who perform best on exams are certainly good test-takers, but they are not necessarily people with the best clinical judgment. One research study of nurse aides assessed competency using both a written test and observation of job performance and found that race predicted poorer scores only on the written test. Another uncovered the use of colloquial language in nursing exams that is not readily understood by non-native English speakers. Most recently, the Association of Social Work Boards revealed glaring racial differences in pass rates for the social worker licensing exam—84 percent of Whites passed on their first try compared to 45 percent of Black test takers, leading to calls that the exam be scrapped altogether.
These patterns are part of well-documented racist traditions. The National Education Association traces the early 20th-century origins of aptitude and achievement exams directly to eugenicists and their quest for racial purity. Shortly after he published A Study of American Intelligence, which claimed that Americans of “Nordic” backgrounds were more intelligent than Americans whose origins were in Africa, Eastern Europe, and the Mediterranean, psychologist Carl Brigham was commissioned by the College Board to develop the Scholastic Aptitude Test (SAT). The 1926 debut of the SAT has been followed by hundreds of other standardized tests that are now administered routinely, from early childhood through the years of formal education and beyond. While their explicit biases have received considerable attention in recent years, implicit biases remain lodged in their content and format.
Meeting the consensus goal of attracting more people of color into the healthcare workforce requires intentional, upstream approaches. To have a shot at performing well on standardized admissions tests, all students should have comparable grounding in anatomy, physiology, math, and other high-quality high school courses with enrichment available for those who need it. Accommodation for students who are not native English speakers and affordable access to test prep courses should also be built into structural solutions designed to elevate equity.
Test results should become an opportunity to identify students who need extra support to succeed, rather than a way to exclude them. One of the challenges for professional schools is that their accreditation is based partly on how many entering students ultimately pass their professional licensing exams, which can discourage institutions from taking a chance on promising candidates with lower scores. Conditional admissions is one way around that, accompanied by support strategies such as mentoring, success coaches, summer programs, and scholarships. Once enrolled, students need ongoing support to navigate the all-too-frequent incivility or more overt forms of racism in classroom and clinical internship settings that lead to higher rates of attrition.,
Given the biases embedded in current testing practices, we also need thoughtful new ways of measuring the knowledge and skills that can inform both school admission offers and qualifications to practice. Nursing and other health professions are beginning to overhaul their licensing exams to emphasize the clinical decision-making that produces quality care and more such commitments are needed. Innovative, inclusive evaluation will widen the candidate pool, benefiting individuals, healthcare systems, and the society that so urgently needs qualified caregivers.
The views expressed here do not necessarily reflect the views of the Robert Wood Johnson Foundation.
