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. 2025 Apr 4;30(1):2486979. doi: 10.1080/10872981.2025.2486979

Advancing health professions education: a review of holistic admissions and competency-based admissions practices

Morgan A Jernigan 1,✉, Kira J Carbonneau 1
PMCID: PMC11980201  PMID: 40183673

ABSTRACT

In this review, we gathered information about competency-based admissions and holistic admissions related to healthcare education to understand current practices better and offer recommendations within the healthcare education field. A literature search was conducted to gather peer-reviewed articles detailing information related to competency-based admissions and holistic admissions that have been implemented in healthcare education, including medical schools, nursing schools, dental schools, and other allied health fields. After screening and the addition of articles through ancestral search, 166 articles were included in this systematic review. The articles were coded for information related to definitions of competency-based admissions and holistic admissions, specific desired competencies, procedures to evaluate these competencies, outcomes of these practices, and the success of admitting well-prepared students using these practices. Results show there is wide variation in established definitions and desired competencies. Similarly, there was some variation in methods for evaluating these competencies with some common practices identified. Lastly, little evidence demonstrates the effectiveness of admitting students who are well-prepared for their programs when competency-based or holistic admissions are employed. There is a need for future research to establish a standard definition for both competency-based admissions and holistic admissions. Desired competencies should be established based on the program’s mission and vision statements for what type of students they want to admit. Lastly, future research needs to focus on the long-term outcomes of implementing these practices.

KEYWORDS: Competency-based admissions, holistic admissions, admissions practices, healthcare education, medical education

Introduction

For many health professions education programs, admissions practices are moving toward a competency-based admission (CBA) or holistic admission (HA) approach rather than evaluating applicants solely on academic metrics, which has historically been the practice [1]. Although the health professions span many different fields including medical, nursing, dentistry, animal science, and more, these education programs have shifted toward these admissions practices to ensure that they are admitting well-prepared students who mirror the ever-changing demographic of the United States population [1–5], to health professions education programs implementing more holistic admissions practices. With this shift, variation in how health professions programs develop and implement CBA and HA, specifically in what competencies and qualities health professions programs desire and how they are assessing those competencies and qualities may attenuate the effectiveness of CBA and HA. This might lead to reluctance of programs in other health professional programs across fields to adopt these types of practices. Best practices for implementation have not been defined, which leaves little guidance for health professions programs that are looking to move toward CBA or HA in their own admissions processes. Therefore, the present review sought to explore all health professions education programs that implement and use CBA and HA.

Study purpose and research questions

The present systematic review was conducted to gather information about CBA and HA practices within health professions fields to better understand practices and related challenges and benefits. Specifically, we asked four research questions:

  1. How do health professional education programs define and operationalize CBA and HA?

  2. When implementing CBA or HA, what do health professional education programs use as the competencies to determine if a student is well prepared for their program?

  3. When implementing CBA or HA, how do health professional education programs assess their set competencies?

  4. How effective are health professional education programs in admitting students who are well prepared to succeed within their programs using CBA or HA?

Findings from this review contribute to evidence supporting future development and implementation of CBA and HA and highlight the needs of future research.

Methods

Selection criteria and search procedures

The aim of this review was to gather and synthesize information about CBA and HA in health professions education programs to better understand how those programs are using and implementing CBA and HA. Selection criteria included peer-reviewed articles published from 2000 to the date that the literature search was completed, in August 2023. This publication range was used to capture how practices changed within the last decade as well as the most current publications related to CBA and HA. Additional inclusion criteria required that articles discussed CBA or HA within health professional education programs. This included programs within animal science, dental, medical, nursing, pharmaceutical, veterinary, and other healthcare and allied health fields, in addition to some residency and fellowship programs. Although there is a wide variation across these types of programs, they were selected to encompass how CBA and HA have been utilized and implemented to inform future practices in fields where these practices are not commonplace. Specifically, this review was done in partnership with the Admissions and Recruitment Committee of the American Association of Veterinary Medical Colleges to inform recommendations to veterinary medical colleges regarding the implementation of CBA and HA. Additionally, due to the lack of the literature synthesizing how CBA and HA have been implemented, the current review was mainly interested in gathering information about the process of using CBA and HA.

Although this project initially aimed to explore CBA practices in health professions education, an initial literature search showed a very small number of articles specifically discussing CBA. However, within this initial search, a related concept of HA emerged as a similar practice that has been more widely implemented. Due to the exploratory nature of this project, and due to the similarities in CBA and HA, it was decided to include both articles discussing CBA and HA to capture a wider scope of the literature surrounding more comprehensive and competency focused admissions practices.

Exclusion criteria included omitting any articles that focused on undergraduate education programs. Additionally, master’s theses and doctoral dissertations were excluded as they did not meet the inclusion requirement of being peer-reviewed. In the initial literature searches, some articles emerged that investigated CBA and HA in fields outside of the health professions, which were excluded from this review.

A comprehensive and systematic search of the medical education and allied health fields education literature was conducted between 15 May and 19 May 2022 using ERIC-EBSCO, MEDLINE (PubMed), Web of Science, CABI (the database for international literature related to agriculture, health, and the life sciences), and CABI VetMed (the database for veterinary information to support practice, based on evidence and continuing education). The search strategy used for each database included 18 searches within each database using the combination of ‘competency based admission’ or ‘holistic admission’ with the following keywords: ‘allied health’, ‘animal science’, ‘dental education’, ‘healthcare’, ‘healthcare education’, ‘medical education’, ‘nursing education’, ‘pharmacy education’, and ‘veterinary education’. Admissions and health education experts including members of the Admissions and Recruitment Committee of the American Association of Veterinary Medical Colleges were consulted in the development of keywords and the selection of databases.

The results from all databases yielded 3,477 total results, and 44 articles were added through ancestral search [6] of included articles, leaving a total of 3,521. Following the deletion of duplicates, 1,180 articles remained to be screened. Screening and decisions regarding the eligibility of articles at each screening phase were conducted by both authors, who met weekly to review decisions and discuss discrepancies. Any discrepancies that arose were discussed till an agreement was met between the authors. Initial screening of the abstracts using inclusion criteria resulted in an exclusion of 882, leaving 298 items for the following phase of review. The next phase of review included reading through each article and extracting pertinent information related to the research questions and excluding any articles that, upon further review, did not meet our inclusion criteria. Following all reviews of the gathered corpus of the literature, 166 articles were retained and included. Details of the database search and results are shown as a PRISMA flow diagram in Figure 1.

Figure 1.

Figure 1.

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PRISMA (preferred reporting items for systematic reviews and meta-analysis) diagram showing the article selection procedure.

Coding protocol

The information extraction process was conducted using a Microsoft Excel spreadsheet [7] which was created using information exported from Zotero reference indexing program [8]. One coder (author 1) reviewed each article individually to determine if they contained any relevant information that addressed the research questions. If any relevant information was found, it was summarized by the coder in an Excel sheet (see supplemental material for template with example articles coded). Due to the large number of articles included, a random subset of articles (20%) was independently coded by a second coder (author 2), following the same method. The decision to have the coders summarize the information that addressed each research question was made due to the fact that the articles were more descriptive and qualitative [9,10]. Through this method, there was an adequate level of agreement between the coders, indicating that they identified the same information that addressed each research question. If present, information that addressed the research questions was extracted from each article. Additionally, each article was coded to indicate whether they discussed CBA or HA, what health professions was discussed, and any challenges noted as a part of implementing CBA or HA within specific practices. Also, due to this review’s exploratory nature, any additional information that could inform future design and implementation of CBA or HA was recorded for thematic analysis.

Results

A total of 166 articles were included in this review. Table 1 lists all articles included, type of education program, country of origin, and whether they were using the terminology CBA or HA. For the articles that were double-coded, there was a consensus regarding the information extracted that addressed each research question.

Table 1.

Articles included in the systematic review including type of program, country of origin, and terminology used.

Article (Listed by Author) Type of Program Country of Origin Terminology Used
Abrams et al. [11] Medical School United States Holistic Review/Assessment
Ackerman-Barger et al. [2] Nursing School United States Holistic Review
Ahluwalia and Swanwick [12], Residency Program for General Practitioners United Kingdom Competency Based Assessment
Ahmed et al. [13] Residency Program for General Practitioners United Kingdom Competency Based Selection
Ahmed et al. [14] Residency Program for General Practitioners United Kingdom Competency Based Selection
Aibana et al. [3] Internal Medicine Residency United States Holistic Review
Akintade et al. [15] Nursing School United States Holistic Admissions
Akoh et al. [16] Dermatology Residency United States Holistic Review
Albanese et al. [17] Medical School United States Competencies
Alpern et al. [18] Medical School United States Competencies
Anderson et al. [19] Medical School United States Holistic Review
Anderson et al. [20] Medical School United States Holistic Review
Andreou et al. [21] Residency Program for General Practitioners Belgium Competencies
Angus et al. [22] Internal Medicine Residency United States Holistic Review
Artinian et al. [4] Health Profession United States Holistic Review
Bajwa et al. [23] Pediatrics Residency Switzerland Competencies
Bajwa et al. [24] Pediatrics Residency Switzerland Competencies
Ballejos et al. [25] Bachelors/Doctor of Medicine United States Holistic Review
Bandiera et al. [26] Medical School Canada Competencies
Barceló et al. [27] Psychiatry Residency United States Holistic Review
Barton et al. [28] Second Degree Nursing United States Holistic Admissions
Baugh [29], Medical School United States Holistic Approach/Review
Bennett et al. [30] Nursing School United States Holistic Admissions/Review
Bice et al. [31] Nursing School United States Holistic Review
Bird et al. [32] Medical School United States Holistic Assessment/Competencies
Bird et al. [33] Medical Residency United States Holistic Screening/Selection/Competency
Blamoun et al. [34] Medical Residency United States Holistic Selection Process
Boatright et al. [35] Graduate Medical Education United States Holistic Review
Booker et al. [36] Dental School United States Holistic Admissions
Brenneman et al. [37] Physician Assistant United States Holistic Admissions/Competency Based Admissions
Brotherton et al. [38] Occupational Therapy United States Holistic Admissions/Review
Buchs and McDaniel [39], Physician Assistant Germany Competencies
Burk-Rafel et al. [40] Medical Residency United States Holistic Review
Bußenius and Harendza [41], Medical School United States Psychosocial Competencies
Canham et al. [42] Physical Therapy United States Holistic Review
Chaviano-Moran et al. [43] Dental School United States Holistic Review/Admissions
Chaviano-Moran et al. [44] Dental School United States Holistic Review/Admissions
Choi et al. [45] Pharmacy School & Other Health Professions N/A Holistic Review/Admissions
Conlon et al. [46] Veterinary School Canada Non-Technical Competencies
Conrad et al. [47] Medical School United States Holistic Review
Coplan and Evans [48], Physician Assistant United States Holistic Admissions/Review
Crandall et al. [49] Veterinary School Canada Communication Competency
Crosby et al. [50] Nursing School United States Critical Competencies/Characteristics
Cunningham et al. [51] Nursing School United States Holistic Review/Judgement
Davis et al. [52] Nursing School United States Holistic Admission Review
DeWitty [53], Nursing School United States Holistic Admissions
DeWitty and Byrd [54], Healthcare Professions United States Holistic Admissions
Diaz et al. [55] Medical School United States Holistic Admissions
DiBaise et al. [56] Physician Assistant United States Holistic Admissions
Dong et al. [57] Medical School United States Holistic Review
Doukas et al. [58] Medical School United States Competencies-Based Account of Professionalism
Eva et al. [59] Health Profession Canada Competencies
Felix et al. [60] Medical School United States Holistic Admissions Process
Fleming et al. [61] Dental School United States Holistic Admissions
Francis et al. [62] Doctorate in Social Work United States Holistic Admissions
Gallahue et al. [63] Medical Residency United States Holistic Review/Behavioral Competencies
Gay et al. [64] Medical School United States Holistic Review
Geng et al. [65] Dental School China Competencies
Glazer et al. [66] Nursing School United States Holistic Admissions Review
Glazer et al. [67] Health Profession United States Holistic Review
Gliatto et al. [68] Medical School & Residency United States Holistic Review
Goldgar et al. [69] Physican Assistant United States Admission Competencies/Noncognitive Skills
Gould et al. [70] Nursing School United States Holistic Admissions
Grabowski [71], Medical School & Residency United States Holistic Review
Grbic et al. [72] Medical School United States Holistic Review
Guiberson and Vigil [73], SpeechLanguage Pathology United States Holistic Review
Hackett and Ruyak [74], Nursing School United States Holistic Review
Hampton et al. [75] Nursing School United States Holistic Admissions Review
Hampton and Apen [76], Nursing School United States Holistic Admissions Review
Hampton et al. [77] Nursing School United States Holistic Admissions Review
Hänsel et al. [78] Medical School Germany Non-Cognitive Competencies
Hanson and Eva [79], Medical School United States and Canada Holistic Review/Competencies
Hanson et al. [80] Medical School Canada Holistic Review/Assessment/Approach
Harrison [81], Medical School United States and Canada Holistic Review
Henderson et al. [82] Medical School United States Holistic Admissions
Henderson et al. [83] Medical School Canada Holistic Admissions
Hofmeister et al. [84] Family Medicine Residency Canada Competencies
Houlahan et al. [85] Nursing School United States Holistic Admissions
Hunker and Robb [86], Doctor of Nursing United States Holistic Admissions/Criteria
Hupp [87], Medical Residency N/A Holistic Admissions
Jerant et al. [88] Medical School United States Holistic Recruitment Approaches
Jones et al. [89] Medical School United States Holistic Admissions
Jung et al. [90] Nursing School United States Holistic Admissions
Katsufrakis et al. [91] Medical School & Residency United States Holistic Review
Katz and Vinker [92], Medical School Israeli Holistic Rubric
Kennedy et al. [93] Medical School United States Holistic Approach
Kerrigan et al. [94] Medical School United States Competency-Based Admissions/Holistic Review
Kim et al. [95] Medical School Korea Non-Academic Competencies
King et al. [6] Medical School United States Holistic Application Review
Knorr and Hissbach [96], Healthcare Professions N/A Competencies/Non-Cognitive Attributes
Ko and Ton [97], Medical School United States Holistic Review
Koenig et al. [98] Medical School United States Personal Competencies
Kreiter [99], Medical School United States Holistic Based-Admission Process
Kreiter and Axelson [100], Medical School United States Holistic/Personal Competencies
Künzel and Breit [101], Veterinary School Austria Social Competency
Lancaster et al. [102] Nursing School United States Holistic Admissions
Langer et al. [103] Medical School United States Holistic Review Process
Lee [104], Medical School United States Holistic Review
Lewing et al. [105] Doctor of Pharmacy United States Holistic Approach using Holistic Composite Score
Lewis et al. [106] Nursing School United States Holistic Review/Admissions
Lewis [107], Accelerated Baccalaureate Nursing United States Holistic Admissions
Maher et al. [108] Occupational Therapy United States Holistic Admissions
Mahon et al. [109] Medical School United States Holistic Admissions/Review and Competency-Based Admissions
Mann et al. [110] Baccalaureate Nursing United States Holistic Admissions
Marshall et al. [111] Hematology-Oncology Fellowship United States Holistic Review Process
Marvin et al. [112] Psychiatry Residency United States Holistic Review
Mason et al. [113] Medical School United States Holistic Review
Matthews et al. [114] Nursing School United States Holistic Admissions/Review
McGaghie and Kreiter [115], Higher Education & Healthcare Professions United States Holistic Review
Morrow [116], Nursing School United States Holistic Admissions Review
Moynahan [117], Medical Education (Undergraduate & Graduate) United States Holistic Admissions
Murray [118], Nursing School N/A Holistic Admissions Process
Murray and Noone [119], Nursing School United States Holistic Admissions
Murray et al. [120] Nursing School United States Holistic Admissions Review Process
Nakae et al. [121] Medical School United States Holistic Review
Nakae et al. [122] Medical School United States Holistic Review
Nehemiah et al. [123] General Surgery Residency United States Holistic Review
Nguyen et al. [124] Health Profession United States Holistic Admissions/Review/Framework
Nohria et al. [125] Pharmacy School United States Holistic Review
Noone and Najjar [126], Nursing School United States Holistic Admissions
Okorie-Awé et al. [127] Pharmacy School United States Holistic Review
Patterson et al. [128] General Practice Residency United Kingdom Competency Based Selection System
Price & Grant-Mills [129] Dental School United States Holistic Application Review
Price et al. [130] Dental School United States Holistic Admissions
Radabaugh et al. [131] Medical School United States Holistic Assessment/Competency
Randall et al. [132] Pediatrics Residency United Kingdom Competency Based Center
Relf [133], Nursing School United States Holistic Review
Roach et al. [134] Baccalaureate Nursing United States Holistic Review
Roberts et al. [135] Medical School Australia Competency-based Selection
Roberts [136], Medical School United States Holistic Review
Robinett et al. [137] Medical School United States Holistic Review
Rosenberg [138], Medical School United States Holistic Review
Schreurs et al. [139] Medical School Netherlands Competencies
Schreurs et al. [140] Medical School Netherlands Competencies/Holistic Review
Schulz et al. [141] Urology Residency Program United States Holistic Review
Schuster et al. [142] Medical School United States Holistic Admissions
Scott and Zerwic [143], Nursing School United States Holistic Admissions
Sims and Lynch [144], Medical School United States Holistic Review
Sklar [145], Health Profession United States Holistic Admissions
Smith et al. [146] Residency Program United Kingdom Competency-based Assessments
Sommers et al. [147] Nursing School Indonesia Holistic Admissions
Sommers et al. [148] Baccalaureate Nursing Indonesia Holistic Admissions
Spector and Railey [149], Neurology Residency United States Holistic Review
Stratton & Elam I [150] Medical School United States Holistic Review
Thomas and Dockter [151], Medical School United States Holistic Review
Thompson and Sonke [152], Nursing School United States Holistic Admissions Review Process
Tidwell et al. [153] Surgical Residency United States Holistic Review
Trivedi et al. [154] Veterinary School United States Holistic Review
VanderMeulen et al. [155] Physician Assistant United States Holistic Admissions
[156] Health Profession United States Holistic Admissions Process
Veesart and Cannon [157], Undergraduate Nursing United States Holistic Admissions
Vermeulen et al. [158] General Practice Residency Netherlands Competency-based Selection
Vermeulen et al. [159] General Practice Residency Netherlands Competency-based Selection
Vick et al. [160] Medical School United States Holistic Review
Wagner et al. [161] Nursing School United States Holistic Admissions
Wall et al. [162] Pharmacy School United States Holistic Review
Wells et al. [163] Dental School United States Holistic Admissions Review
Wilcox and Lawson [164], Health Profession United States Holistic Review
Wildermuth [165], Physician Assistant United States Holistic Admissions Review
Wilson et al. [166] Dental School United States Holistic Review
Wise et al. [167] Physical Therapy United States Holistic Review
Witzburg and Sondheimer [168], Medical School United States Holistic Review
Wros and Noone [169], Nursing School United States Holistic Admissions
Zaidi et al. [170] Medical School United States Holistic Evaluation/Approach
Zerwic et al. [171] Nursing School United States Holistic Admissions
Zimnicki et al. [172] Nursing School United States Holistic Admissions Review
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This table includes all articles that were included in the present systematic review. Type of program, country of origin, and terminology for each article are included.

Article characteristics

Articles included were published between the years 2000 and 2023. The most common healthcare education programs included were medical schools (n = 54, 32.5%), nursing schools (n = 34, 20.5%), dental schools (n = 9, 5.4%), and health professions (non-specified; n = 9, 5.4%). Other included programs were more specialized (see Table 1 for full list). Most articles focused on healthcare education within the United States, however other countries were mentioned including Canada, the Netherlands, and the United Kingdom (see Table 1).

RQ1)

How do health professional education programs define and operationalize CBA and HA? The first aim of this systematic review was to identify how health education programs define and operationalize CBA. Thirty-one articles explicitly discussed competencies related to admissions in some capacity. Those articles differed in the terminology for what they called ‘competencies’. For example, articles often referenced these competencies as non-cognitive skills, non-cognitive attributes, non-academic competencies, non-technical competencies, or psychosocial competencies. Like the variation in terminology, definitions of competencies related to admissions or competencies desired in applicants varied widely, with more than half of the articles not providing an explicit definition of CBA. Kerrigan et al. [94] came the closest to providing an outcome of CBA, stating that it provides greater flexibility and reduces barriers to admissions. Similarly, multiple articles used the terminology ‘competency-based selection’ but like CBA, no concrete definition was provided. Other articles described foundational competencies or skills including empathy and sensitivity, communication and other professionalism skills, and critical thinking that were deemed necessary for practicing physicians or other related professionals. However, Kerrigan et al. [94], along with seven other articles [32,33,37,79, [100,109,140], mentioned competencies or CBA as either equivalent or part of HA. Due to this evidence, this review will discuss findings related to both types of admissions practices.

The remaining 135 articles discussed holistic admissions or holistic review which were found to be used interchangeably. Sixty-one of those articles defined holistic review using a definition provided by the Association of American Medical Colleges (AAMC) [173]

… a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics (E-A-M) and, when considered in combination, how the individual might contribute to value as a medical student and future physician. (p. ix)

In addition to this definition, many articles also cited the core principles that the AAMC recommends schools integrate into the holistic admission process. These principles include (1) having selection criteria be broad in nature and linked to the school’s mission and goals, as well as promote diversity, (2) that the selection criteria include experiences and attributes in addition to academic performance, and (3) that schools should consider each applicant’s potential contribution to both the school and the field, allowing the school to weigh and balance the range of criteria for admission to their programs.

Sixty-two other articles that describe HA, had definitions which followed similar themes of the AAMC definition, stating that holistic review/admissions focus on reviewing applicants’ qualities, characteristics, attributes, experiences, and background to gain a more holistic or complete picture of each applicant and how they might contribute to the mission and goals of the program as well as how they might contribute to the field (e.g. [102,127,129,150,164]. Furthermore, increasing diversity was noted as the main goal of designing and implementing holistic admissions or review. For example, Anderson et al. [20] stated that holistic review has been characterized to address racial health disparities by increasing physician workforce diversity.

With the lack of a clear definition for CBA or HA, many programs have noted that there is a demand for consensus which would aid in explaining the need for changes in admissions to schools’ upper administration and stakeholders, which has been noted as a challenge to implementation [36,66,110].

RQ2)

When implementing CBA or HA, what do health professional education programs use as the competencies to determine if a student is well-prepared for their program? Our second goal was to identify what competencies health education programs were using to identify well-prepared students to admit to their programs. Competencies listed from programs that were discussing CBA or using competencies as part of admissions, included communication skills, personal and professional development, leadership, empathy and sensitivity, teamwork, conceptual/critical thinking and problem-solving skills, along with other personal attributes (for full list see Table 2). Additionally, articles also mentioned clinical competencies or required a specific level of medical knowledge as a desired competency for admission.

Table 2.

Competencies mentioned in articles discussing CBA by count and percentage.

Competency Number of Articles Mentioned Percent of Articles Mentioned
Communication 20 12
Ethical/Integrity 13 8
Medical/Clinical Knowledge 12 7
Adaptability/Coping with Stress 10 6
Teamwork/Collaboration 10 6
Empathy/Sensitivity 8 5
Critical Thinking 6 4
Interpersonal/Social Skills 6 4
Professionalism 6 4
Leadership Experience 4 2
Problem Solving 4 2
Resiliency 4 2
Cultural Competence 3 2
Motivation 3 2
Personal Management Skills 3 2
Service Oriented/Community Service 3 2
Sound Judgement 3 2
Capacity for Improvement 2 1
Clinical Experience 2 1
Health Advocate 2 1
Altruism 1 1
Cognitive Ability 1 1
Scholar 1 1
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This table includes all the competencies listed in articles discussing competency-based admissions.

Comparably, articles discussing HA included similar characteristics or qualities, however, programs integrated those characteristics and qualities into the E-A-M model provided by the Association of American Medical Colleges [173]. Experiences that admissions committees deemed important for evaluation included clinical exposure, community service, research, military experience, hardships, experience with diverse cultures, and extracurricular experiences. Attributes that were seen as important for evaluation in the admission process included socioeconomic status, gender, race, ethnicity, leadership, altruism, communication skills, collaboration/teamwork, critical thinking and problem-solving skills, and ethics. And academic Metrics that were noted as important for evaluation in the admissions process included grade point average (GPA) and field-specific entrance exam scores (i.e. Medical College Admissions Test, Graduate Record Exam, Test of Essential Academic Skills, etc.). Although not all programs that discussed HA used the E-A-M framework when determining the desired characteristics and qualities of applicants, most other characteristics and qualities listed can fall into this framework. See Table 3 for full list of characteristics included in the articles.

Table 3.

Qualities, attributes, and experiences mentioned in articles discussing HA by count and percentage.

Quality, Attribute, or Experience Number of Articles Mentioned Percent of Articles Mentioned
Service Orientation/Community Service 31 19
Leadership Experience 24 14
Life Experiences/Adversity 19 11
Communication 14 8
Diversity (Student Identifies with an Underrepresented Group) 14 8
Socioeconomic Status 14 8
Race/Ethnicity 13 8
Ethical/Integrity 12 7
Gender 12 7
Teamwork/Collaboration 12 7
Clinical Experience 11 7
Motivation 10 6
Critical Thinking 9 5
Desire to Learn/Intellectual Curiosity 9 5
Altruism 8 5
Cultural Competence 8 5
Language Proficiency/Multilingual 8 5
Professionalism 8 5
Resiliency 8 5
1st Generation College Student 7 4
Good Self-Concept/Confident 7 4
Interpersonal/Social Skills 7 4
Work Experience 6 4
Empathy/Sensitivity 5 3
Age 4 2
Health/Patient Advocate 4 2
Problem-Solving 4 2
Veteran/Military Service 4 2
Extracurricular Activities 3 2
Geographic Location (Rural, Urban, Vicinity to Program) 3 2
Capacity for Improvement 2 1
Clinical Knowledge 2 1
Disability (Self-Identified) 1 1
Manual Dexterity 1 1
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This table includes all the qualities, attributes, and experiences that were listed in articles discussing holistic admissions.

RQ3)

When implementing CBA or HA, how do health professional education programs assess their set competencies? Aim three of our review was to evaluate how healthcare education programs that have implemented CBA assess their target competencies. Although a wide range of desired competencies were identified, many programs used similar methods of assessing those competencies. Overall, there were common methods for evaluating competencies across programs, and methods of assessment did not differ between programs that employed CBA or HA.

Interviews

Across the articles, the most cited method used to review applicants and assess desired competencies was interviews. Forty-two percent of papers cited interviews as the most frequent tool for assessing competencies. Traditional interviews as well as more progressive forms of interviews were mentioned, including multiple mini-interviews. Multiple mini-interviews are an increasingly popular form of interviews in the health sciences fields [96]. The most common format for multiple mini-interviews consists of several short assessments, or stations, that can last anywhere from 10 minutes to an hour. In these assessments, applicants are asked questions by an interviewer or asked to participate in a role-play scenario where they are observed by individuals participating in the scenario or individuals viewing the scenario [96]. During multiple mini-interviews, interviewers and observers are looking for markers of desired competencies within applicants. Multiple mini-interviews have gained popularity due to their ability to have multiple individuals observe and assess applicants while also providing an opportunity to see how they react to various scenarios that they might encounter in their field.

Standardized video interview

In 2016, the AAMC introduced the Standardized Video Interview where applicants were asked to provide oral responses to several competency-focused questions while being video recorded [33]. Although this method has been used by many different types of programs, it is a particularly well-used method for residency program admissions [33]. Applicants’ responses are then evaluated and scored, like a traditional interview, where the reviewer is looking for evidence that the applicants possess the desired competencies. This also allows multiple reviewers to view each applicants’ responses to ensure a consensus regarding each applicant. The Standard Video Interview is seen as an alternative to traditional interviews that do not require organizing a real-time interview, allowing students to submit their responses at a time of their choosing.

Personal statements and essays

Personal statements and essays were found to be other popular methods of assessing competencies in admissions for healthcare education programs. Although these tools have been staples of admissions processes [174], standardization of these tools has been a key practice when implementing them into CBA and HA. Including more explicit and detailed prompts and questions for personal statements and essays has helped standardize these assessments. An example essay question from an accelerated Bachelor of Science in nursing program’s HA process asks applicants ‘Why do you want to be a nurse? Include your academic, professional, and life experiences and how they are relevant to the nursing profession. Include your professional nursing goals’ [106]. By standardizing these tools, programs have noted an improvement of interrater reliability and predictive validity compared to non-standardized tools [100].

Letters of recommendation

Standardized letters of recommendation have also become more common in admissions, with programs providing form letters of recommendation to recommenders rather than giving them a prompt and letting them structure the letter how they like. Additionally, standardized letters of recommendation have led to greater inter-rater reliability compared to non-standardized letters, in addition to being effective in mitigating bias, which is commonly noted as a risk of using non-standardized letters [153]. Standardized letters of recommendation offer a faster and less subjective alternative that has been used by many residency programs during the admissions process [153].

Situational judgement tests

Situational judgement tests were cited as an evaluation tool for CBA and HA in 10% of papers reviewed. Situational judgment tests ask applicants to indicate how they would respond to various scenarios presented to them in either a text, video, or animated format. Responses can be in the form of multiple-choice options, identifying the most and least effective responses and/or in the form of open-ended questions depending on how the program is evaluating and ‘scoring’ the applicants [37]. Situational judgement tests have been found to be good indicators of professional attributes, and that unlike some other methods of evaluating non-academic attributes, situational judgement tests are often cost-efficient [39].

Other tools

Other tools used to assess competencies in CBA and HA that were mentioned within the papers included psychological inventories and assessments, resumes and curriculum vitas, and other tests of clinical or related knowledge. Regardless of what tools were described in the articles, scoring systems, or ranking for each competency were used or proposed to compare applicants to aid in admission decisions.

Regardless of what method or tool is implemented, many articles noted the importance of training interviewers, observers, and reviewers in how to evaluate and score (if applicable) each candidate. Lack of consistency in reviewing has been seen as a challenge of CBA and HA, which many programs have solved by implementing a rigorous training program and explicit instructions for reviewing applicants, as well as constructing rubrics for different methods of evaluation. This increased training and rubrics has also been used to avoid implicit or unconscious bias within admissions decisions. As previously stated, many programs implemented HA as a strategy to diversify their programs and respective fields. The AAMC has developed a range of resources aimed at helping programs address this concern, including online resources, virtual seminars, and group workshops. Robinett et al. [137] noted participation in a 4-day train-the-trainer workshop facilitated by the AAMC was aimed at mitigating any bias throughout multiple points of the selection process, including screening, interview, and committee discussion and decisions.

RQ4)

How effective are health professional education programs in admitting students who are well prepared to succeed within their programs using CBA or HA? The last aim of our review was to evaluate any evidence on how effective CBA was at admitting students who were well-prepared. Due to the varying purposes of articles included and the current state of the field, there was paucity of information related to CBA effectiveness. However, Matthews et al. [114] and Zerwic et al. [171] found that after implementing HA for the University of Illinois Chicago, College of Nursing, they saw an increase in the diversity of admitted students without seeing a decrease in academic metrics compared to previous admissions cycles where HA was not used. Specifically, they found no statistical differences in science grade point average (GPA) at admission, overall GPA, two-year graduation rate, or first-time NCLEX pass rates of the first two graduating classes of bachelor’s degree students under the new admissions policy. Additionally, Hunker and Robb (2021) found that 81.6% of admitted applicants were identified as being academically successful after their first semester in a Doctor of Nursing Practice program. These findings, although isolated to these specific programs, support the view that implementation of CBA and HA does not reduce the quality of applicants, which is why some faculty hesitate to support implementation [45,110].

In addition to the findings from Matthews et al. [114] and Zerwic et al. [171] regarding an increase in diversity, 48 other articles provided evidence that implementing CBA or HA resulted in increased diversity, specifically race/ethnicity, gender, first-generation students, and underrepresented minorities within their respective fields. Although these studies did not mention how well-prepared students are, they do offer support that CBA can help identify diverse candidates. Eighty articles in this review cited diversity as a goal and/or outcome of implementing CBA and HA.

Discussion

This review explored the use of competency-based admissions and holistic admissions within health professions education programs to better understand these practices and inform future implementation. Our first goal was to define and operationalize CBA and HA. However, we found a lack of a clear definition of CBA, whereas HA has been well-defined by the Association of American Medical Colleges [173]. Despite the lack of a clear definition for CBA, many articles cited very similar foundational principles to HA. Standardizing HA definitions and processes could enable better systematic study and lead to improvements in admission practices.

Regarding the second goal of this review, the competencies and qualities that were assessed were relatively consistent across CBA and HA. However, there was little evidence to support that these competencies and qualities align with program mission and goals. The third goal of this review was to determine how programs evaluated competencies and qualities. Findings showed that many programs are implementing updated traditional assessments, such as multiple mini-interviews (MMIs). One consideration that programs must consider as they begin implementing these methods is the resource demand that they can have on programs. However, changes in practices that resulted from the COVID-19 pandemic, such as shifting to virtual interviews, might offer a solution to the logistic demands of these methods.

Lastly, no evidence was found regarding the effectiveness of CBA or HA in admitting well-prepared students into programs. However, some studies provided evidence that the use of CBA and HA has been associated with increased diversity. The findings of this review demonstrated a significant gap in the literature regarding CBA and HA. While the findings of this review were able to address some of our research questions regarding the types of competencies and qualities programs are interested in and how they assess them, more information is needed to get a complete picture of CBA and HA in health professions education. Although the current literature on CBA and HA focuses on increased diversity, there is a gap in the literature regarding other outcomes of CBA and HA. However, future research should investigate the impact of CBA and HA on student success, including academic performance, professional readiness, and career trajectories. Such research is critical to provide a more comprehensive picture of the implications and benefits of CBA and HA.

Limitations

There are some limitations to this review. First, the articles included in this review focus on CBA and HA across multiple different health professions education programs. Although this was done to gain a general understanding of these admissions practices within health professions education programs, there may be differences in admissions criteria, specific trends, and standards for admissions across these programs. Second, the articles included in this review came from multiple countries. Although this review wanted to gather information about how health professions programs implement CBA and HA, each country has its own educational structures that have its own nuances and challenges. Therefore, there may be inherent differences in how CBA and HA are implemented.

Supplementary Material

Excel Coding Template.xlsx
ZMEO_A_2486979_SM8954.xlsx (10.9KB, xlsx)

Funding Statement

This work was supported by the American Association of Veterinary Medical Colleges. This work was presented, in part, at the American Education Research Association Conference, April 2024, Pennsylvania Convention Center, Philadelphia, PA, and at the American Association of Veterinary Medical Colleges Annual Conference, April 2024, Washington, DC The American Association for Veterinary Medical Colleges.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2025.2486979

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