A scoping review of admission criteria and selection methods in nursing education

Background Nursing education institutions are required to select and train applicants who have appropriate characteristics for delivering effective healthcare. Unlike other healthcare professions and despite the need to attract and select a competent workforce, there has been no comprehensive analysis of the selection criteria and methods used to recruit nursing students. As there is relatively limited prior research available, we conducted a scoping review to explore and synthesise the existing evidence regarding admission criteria and selection methods of nursing students and for the purpose of identifying an agenda for future research in this field. Methods Our scoping review follows the Arksey and O’Malley five-step proposition including identifying the research question and relevant studies, study selection, tabulation of data, and summarizing and reporting the results. Seven databases (PubMed, CINAHL, Scopus, ERIC, SID, Irandoc and PsycINFO) were searched systematically using relevant keywords. Articles on admission of undergraduate nursing students published in both English and/or Persian from 2006 to 2019 were retrieved. Results Existing research evidence suggests that nursing students are largely selected on the basis of two criteria - “cognitive-academic abilities” and “non-cognitive abilities.” Cognitive-academic abilities were assessed in four main dimensions of mathematics, language, natural sciences and reasoning skills mainly through standardized tests and academic records. Our review shows a wide range of non-cognitive characteristics are evaluated in nursing applicants including: morality, interpersonal communication skills and psychological strength. The selection method most commonly used to assess characteristics was through interviews (panel interviews or multiple mini interviews). Other methods included references, personal statements and personality assessment tools. Conclusions This is the first scoping review of literature regarding nursing education selection and recruitment. Results can be used to inform nursing education policymakers and institutions in the design of their selection practices. Future research should concentrate on the evaluation and improvement methods of student selection including content and predictive validity analysis of multiple mini interview and standardized tests, development of cost-effective selection methods and job analysis studies to identify specific non-cognitive characteristics for nursing.


Background
Student selection in the health professions is increasingly being recognised as an important issue [1]. The ultimate goal of student selection is to identify who will go on to be the most effective clinicians in delivering patient care, which ultimately relates to positive health outcomes [2]. Selection of students who can successfully complete their education and have necessary professional qualifications is currently considered a main challenge of health education institutions in the world [3].
Nurses, who play a key role in promoting individual and community health [4], comprise the largest group of health care workforce [5] with approximately 35 million nurses and midwives worldwide. Choosing the right student for the nursing profession will ensure job compatibility, improves nursing workforce performance in the future and ensures the safety and well-being of patients [6]. Additionally it maximizes the effectiveness of health systems and can ultimately lead to improved nursing care. It also helps to better the public image of the nursing profession in the society [7].
Recently, the number of nursing program applications has increased both internationally and in Iran [8,9]. One of the major challenges in the nursing education is selecting competent applicants who are most likely to accomplish the training program successfully, and make a long-term effective contribution to their profession, the general public, and the community [10]. This issue has received much attention in recent years, largely due to growing concerns of diminishing quality of nursing care, high attrition rates, limited resources and students' academic failure [11][12][13]. In addition, nursing instructors and educators [14] have reported a rise in unprofessional attitudes and behaviours of nursing students, further demonstrating the need for the assessment of the professional skills of applicants to nursing, in addition to academic performance [7].

Selection for nursing education in Iran
Selection methods for entering the nursing profession is considered a key nursing challenge in Iran. Currently, the fit between nursing applicants' personal characteristics and requirements of the nursing profession are not considered. This has reduced the efficiency of nurses' performance and impeded the development and maintenance of a sustained, efficient workforce [15,16]. Since the 1980s, the only criterion utilised in Iran has been success in the University Entrance Exam, which takes the format of a multiple choice written test [17]. A large number of graduated from high school sit the entrance exam annually and admit different majors based on their ranks in this exam [18]. This exam caters for all majors, and hence it cannot take specific features and perquisites for each profession into account [19], where arguably criteria for the health professions may be different to other disciplines and professions.
Several obstacles have impacted the nursing student admission system and nursing profession in Iran in recent years. A significant number of high school graduates admitted to nursing schools through the current system leave before completion because of the mismatch between their personal traits and those required by the nursing profession or they lack sufficient motivation to become qualified nurses [20]. Another important negative effect is reduced efficiency and effectiveness of nurses in their job duties, which is often attributed to sub-optimal selection. In most cases, failure of individuals to effectively perform their job in the organization arises from inconsistency of their psychological characteristics with the job they are undertaking rather than the lack of technical skills or intelligence [21]. This can lead to reduced satisfaction, job failure [22], increased job burnout, decreased performance [21] and reduction of nursing care quality [23].
Nursing education institutions are responsible for selecting and training applicants who have the characteristics necessary for developing and transforming the future of the nursing profession [24,25]. They are required to have clear admission policies relating to the selection process and minimum admission criteria [26]. However, there is a Lack of information based on research evidence regarding nursing students' admission criteria and selection practices. Given this knowledge gap and the importance of selecting the right candidates for entry into the nursing profession, a comprehensive analysis of existing research on admission criteria and selection methods of undergraduate nursing students was conducted.

Objectives and review questions
This study aimed to review existing research evidence regarding nursing students' selection criteria and selection methods. The research questions were: 1) What criteria are being used to select applicants? 2) Which selection methods are being used to assess applicants as part of selection into undergraduate nursing students? 3) What does the evidence show regarding the predictive validity of selection methods with students' academic performance?

Study design
This scoping review was conducted based on the PRIS MA guidelines (see the supplementary data 1) [27,28]. The five steps included: identifying the research questions; identifying relevant studies; study selection; tabulation of data; and collating, summarizing and reporting the results [29].

Search strategy
Systematic searches were conducted in databases from April to August 2019 by two researchers. Preliminary searches on PubMed and CINAHL for student selection criteria and methods were performed using the keywords "criteria", "selection methods", "nursing school", "admission criteria" and "nursing student." The title and abstract of articles were reviewed and new keywords were identified for the full article search. The final search was performed using the following keywords in PubMed, SID, Irandoc, CINAHL, Scopus, ERIC and PsycINFO databases using the Boolean operators "OR" and "AND": -"Criteria" OR "cognitive" OR "Non cognitive" OR "admission criteria" -"nursing student" OR "nursing application" OR "nursing education" OR nursing candidate -"selection" OR "admission" OR "entry" OR "entrance" OR "recruitment" OR "prerequisite" -"selection methods" OR "Selection process" -"test" OR "interview" OR "predictive" OR "psychometric" OR "personality" OR "emotional intelligence" OR "aptitude test" OR "academic record" OR "academic attainment" OR "performance" OR "success" Search for Persian Literature had no result. The references of the selected articles were also searched manually.

Study selection
Studies were selected according to inclusion and exclusion criteria. Inclusion criteria were Persian and English articles on admission of undergraduate nursing students published from 2006 to 2019. Commentaries, editorials and opinion papers were excluded. The title, abstract and full text of the articles was reviewed by four researchers (VZ, AG, LV AND FB) according to the inclusion and exclusion criteria. Any disagreements resolved by discussion and consensus with the research team. The flow diagram for the article selection process is summarized in Fig. 1.

Data extraction
Key information extracted from included articles included the author, year, country, main purpose, participants, study design and main results by two reviewers. The data chart was performed independently by two reviewers and then the results were discussed. Data charting was continuously updated in an iterative process ( Table 1). The extracted data then were analyzed and interpreted.    The upper-secondary diploma coursework grades, unlike the admission test score, correlates positively with final degree grades and GPA of exam scores. Students who did not graduate within 6 semesters had lowest grades concerning their upper-secondary diploma coursework un like the admission test score.

Doctoral dissertation
To describe and compare reading comprehension of two groups of students, a prenursing student group and a senior nursing student group.
Two groups of students, a pre-nursing student group (n = 44) and a senior nursing student group (n = 44).
Descriptive design.
Pre-nursing and senior nursing students scored below the standardization norms for comparable college students, and senior nursing students also scored below the standardization values for other health profession students at a comparable level of education.

Literature search
A total of 5417 articles were found from databases search, duplicate articles were removed, and 3045 articles entered the title and abstract review phase. After excluding unrelated studies, the full text of 182 articles were evaluated in terms of inclusion criteria and 44 articles were included in the final review.

Study characteristics
Most studies (n = 20) were from the USA followed by the UK (n = 9), Australia (n = 4), Finland (n = 3), Canada (n = 3) and one study from each of the countries New Zealand, Pakistan, Oman, Sweden, Africa, and Italy. Thirty-two articles were research studies, 4 were review articles and 8 were thesis and doctoral dissertations. Study characteristics are presented in Table 1.

Nursing students' selection criteria
The Review identified that nursing students are selected based on two criteria: (1) cognitive-academic abilities and (2) non-cognitive abilities. These two criteria are explained below.

Cognitive-academic abilities
Most studies considered cognitive-academic abilities as an essential criterion for nursing student admission. The four most common cognitive-academic competencies evaluated in nursing applicants included (1) reasoning skills (analysis ability, deductive and inductive reasoning, inference, critical thinking, problem-solving, decision-making evaluation, logic); (2) mathematical skills (math, numeracy, basic calculation, applied math); (3) language skills (English writing, reading comprehension, reading, vocabulary, English reading, general knowledge of the language, word knowledge, literacy, verbal); and (4) natural science skills (chemistry, physics, biology, anatomy and physiology). Nursing applicants were assessed for language and mathematical skills in the majority of studies, and few studies focused on assessing reasoning and natural science skills of nursing applicants (Tables 1 and 3).

Non-cognitive abilities
Reviewed studies revealed that non-cognitive abilities examined in nursing applicants include communication skills, teamwork, dynamism, morality, psychological strength, Emotional intelligence and warmth (As seen in Table 2).

Methods used to assess nursing student selection criteria
Results of the review indicated that two main methods are used to assess the cognitive-academic competencies of nursing applicants are: 1 On-site test for selection (conducted either before or during the Student selection process): According to the reviewed studies, standardized tests are often used to measure cognitive-academic abilities in this method (Table 3). 2 Academic achievement records: In most studies, academic records have been used as the most common criterion for selecting a student for nursing education, typically based on the high school grade point average (GPA) [8,13,14,32,35,37,45,46,49,52,58,61,68]. Studies have reported prior academic achievement of applicants in general, but it was not possible to further analyze the specific cognitive-academic abilities acquired from academic records of applicants.
Based on the review results, the TEAS was the most commonly used test, yet reliability of test was only confirmed in one study (NDRT test: Nelson-Denny Reading Test) [50]. The reliability or validity of other selection tests reported based on previous assessments by instrument developers in the studies [36,39,47,51,55,59,61]. In other studies, the reliability and validity of the test used was not reported [30,31,34,40,41,43,49,56,57,60].
Four main methods were found to assess the noncognitive abilities of nursing applicants. Interviews (panel interviews or multiple mini interviews) are the main method used to assess communication skills, teamwork morale, ethical insights, and empathy. Personal statements were another selection method, commonly used to assess motivation and self-assessment of personal characteristics. Some nursing institutes also use recommendation letters provided by teachers and there was limited used of personality tests ( Table 1).

Methods of student selection and relationship with academic performance
The relationship of selection methods and academic performance was reported positive in 20 articles and neither positive nor negative in 5 articles. The relationship of academic performance with standardized tests (15 articles) and academic records (13 articles) has been examined more than other methods of student selection. Only two articles reported a positive relationship between interviews (individual interview and multiple mini interviews) and academic performance. In most studies, academic success and passing the NCLEX exam (National Council Licensure Examination) have been used as a criterion for assessing academic performance. The relationship between the selection methods (i.e. HSRT: Health Sciences Reasoning Test) and clinical performance has been examined in only one study without identifying a positive or negative relationship (Table 4).

Discussion
This study assessed existing published literature on the admission criteria and selection methods of undergraduate nursing students. Results showed that academiccognitive and non-cognitive abilities are the main two criteria in the process of selecting students for nursing programs. According to the results of this review, the academic-cognitive abilities of the applicants are mainly examined through the academic records and standardized tests, and the non-cognitive abilities are investigated through the interviews, personal statements and references.   [49] General education, mathematics, logic, biology, chemistry, physics Onsite student selection processes: Interview MacDuff et al. 2016 [62] Cognitive attributes: problem-solving Review of the selected studies showed that academic abilities of applicants are assessed in three main areas of mathematics, language and natural sciences skills which aligns with the World Health Organization recommendations for selection criteria in nursing students [26]. Basic science skills were suggested in previous studies without any complete explanation. In this study, the most important basic science skills were identified. According to the results of this review, academic abilities are good predictors of academic success of nursing students [8,39,40,51,56,57,61].
Cognitive abilities were another criterion for selecting the nursing student in the reviewed studies. Although the cognitive abilities are very important for all students of the higher education institutions [70], however, the investigation of this criterion among the nursing applicants is of special importance [67]. Cognitive abilities are very crucial in the complex working environments, including the nursing [70]. The nursing field is complex and the undergraduate students must acquire the necessary qualifications for nursing in a relatively short period of time [71]. Therefore, the cognitive preparation is necessary for the individuals to succeed in the theoretical and clinical courses [72]. The research findings also indicate that the nursing applicants who have been investigated according to the reasoning skills have the theoretical and clinical success during their training [59]. The nurses' cognitive abilities play a key role in the problem-solving skills, the clinical decision-making power, and as a results diagnosing the patient needs and selecting the best nursing practices [73,74]. This could directly affect the patient's safety and improvement [75]. However, the results of this study showed that cognitive abilities of applicants have been assessed in few articles. In this regard, the European Federation of Nurses Association has acknowledged that although this skill is considered an important competence in nursing education, it is usually neglected and under-valued when selecting nursing students [76]. These findings demonstrate the need for assessing reasoning skills for selecting nursing students.
The results of this study showed that the cognitiveacademic abilities of applicants are assessed mainly through academic records or standardized tests [37,46]. In order to evaluate this ability, the research evidence suggests that the standardized tests and academic records are more relevant to the future academic performance of the nursing students than the other methods (interview and non-standardized tests) [6,30,36,51,55,57,59,61], and are better predictors of nursing students' academic success [30,39]. However, the findings of this study indicated that none of the standardized tests evaluate all of the four cognitive-academic skills in one test. On the other hand, there is little research evidence on the validity and reliability of nursing standardized tests [30, 31, 34, 46, 49, 51, 56-58, 60, 61]. In addition, the most important criticism of using academic records as a selection criterion is heterogeneity of scores, since they are obtained from different institutions, leading to bias in the selection of nursing students [8]. It is worth mentioning that academic records can be a good criterion for students' selection provided that valid standardized tests are nationally conducted.
The non-cognitive skills were another criterion for selecting the nursing student in the reviewed studies. It is important to select nursing students with noncognitive, professionally tailored characteristics to provide safe and high quality care [77]. According to research findings, traits such as empathy and morality of nursing students do not change during their training which highlights the importance of their assessment when entering the nursing profession [78]. Researchers have concluded that academic-cognitive abilities are necessary but not sufficient for becoming a qualified nurse and this criterion alone cannot guarantee ethical and appropriate practice in nursing [66]. Individual values, interests and motivations are not considered in this approach, and individuals with high academic-cognitive abilities cannot be considered competent and qualified nurses merely through education [66]. According to Ones et al., cognitive abilities along with non-cognitive abilities lead to better performance of an individual in a job [79]. Therefore, non-cognitive characteristics should be considered a key criterion in nursing student's selection [8,66].
This review indicates that assessment of non-cognitive abilities is generally done through interview (traditional, multiple mini interview), personal statements, references and personality assessmentt [8,32,37,45,47]. Interviews are the most common method for assessing noncognitive abilities such as communication and teamwork skills [32,37,45,47,52,58], despite evidence that traditional interviews lack predictive validity and are not a powerful tool for selecting nursing students [8,45,80]. Interviews are strongly influenced by interviewers [81] and hence are highly associated with bias in the selection process [37]. More recently, some universities have begun using multiple mini interviews to select applicants [47], which have been found to have higher validity and reliability compared to traditional interviews [47,58]. However, limited studies exist on the predictive validity of MMI [6,47]. Construct validity of MMI remains a challenge, and there is insufficient consensus on the dimensions that applicants need to be examined in multiple mini interviews and thus requires further research evidence [47,52]. Multiple mini interview is also a costly method because it requires station design as well as more manpower and role players [47,82,83]. Personal Table 4 The Relationship between student selection methods and academic performance in reviewed studies

Selection methods
Author and years P-value for relationship of student selection methods to academic performance McGahee et al. 2010 [35] .002a Interviews Gale et al. 2016 [6] .03b Schmidt & MacWilliams 2011 [37] <.01b a = Pearson correlation coefficient, b = regression analysis NCLEX-RN National Council Licensure Examination-Registered Nurse statements are another method used to assess noncognitive characteristics including motivation and selfevaluation [8,45]. There is little research evidence to confirm the predictive validity of personal statements, and most research evidence indicates that this method lacks validity and reliability as a selection tool [8,45,46,52]. On the other hand, the content of personal statements may lead to unfair judgment in the selection of applicants [84]. There is limited studies regarding the use of references as a student selection method and their use is not recommended due to low reliability and validity [8,46,52]. Despite these findings, most nursing schools widely use personal statements and references for student selection. Some studies have suggested personality assessment to assess non-cognitive abilities. The results of a Meta-analysis on the predictive validity of personality assessment showed an insignificant relationship between personality predictors and job criteria [79]. Despite low validity, these tests have been widely used in selecting health care professionals for many years [85].
In addition to the above-mentioned methods, selection centers and situational judgment tests are also used for assessing the non-cognitive abilities suggested for medical students. Research evidence regarding the use of selection centers for selecting medical applicants indicates high validity of this method, but it can be costly for institutions [86,87]. Situational judgment tests have also been recognized as a reliable valid method for assessing non-cognitive abilities and are used to examine a wide range of non-cognitive traits for selecting many largescale job applicants [88,89]. Despite the use of situational judgment tests for student selection in some health care professions [90][91][92][93][94], no research evidence was found regarding the use of this method for nursing student selection.

Limitations
The findings of this scoping review must be interpreted with caution because the quality of the selected articles was not evaluated. Therefore, articles of varying quality were included in this study and the results may be of limited reliability.

Conclusion
The results of this scoping review can be used by nursing education policymakers and institutes for comprehensive assessment of applicants in terms of their suitability for the nursing education. Both academiccognitive and non-cognitive abilities should be considered when selecting a student for entry into nursing education. Future studies should be directed toward assessing and improving methods of student selection. According to the reviewed studies, there is limited evidence on content and predictive validity of selection methods including MMIs and standardized tests. Longitudinal studies (examining students during the course of study and career) are required to assess predictive validity of these methods. The findings of this review showed insufficient consensus among researchers about which non-cognitive characteristics should be examined in nursing applicants. Further research is required to identify attributes considered essential for success during nursing training and nursing practice. The relative contribution of each selection criterion in the student admission system is also unclear; therefore, further research is needed to weigh the selection criteria. Given the lack of research evidence on the situational judgment tests in nursing education despite its costeffectiveness and large-scale feasibility, it is suggested to design these tests to examine the non-cognitive characteristics of applicants.
Authors' contributions VZ: concept design, data collection, analysis and interpretation, drafting of manuscript; AG: participated in the study design, data collection and analysis, manuscript revision; LV: participated in the study design and analysis; FB: data collection, analysis and interpretation, drafting of manuscript; ML: analysis and interpretation, critical revision of manuscript. All authors read and approved the final manuscript.

Funding
This study was financially supported by Tabriz University of Medical Sciences. The funding part had no role in the design of the study, the collection, analysis and interpretation of the data, or in writing the manuscript.

Availability of data and materials
The datasets used and/or analysed the current study are available from the corresponding author upon reasonable request.
Ethics approval and consent to participate Approval code of ethics with number: IR.TBMED.REC.1397.583. Consent to participate: Not applicable