LR Explor/The Nurse Leader Role

LR Explor/The nurse leader role in recruit.

Nurse Leaders as Recruiters

Nurse leaders serve an integral role in the field to demonstrate skill in recruitment of future nurses. To do this they must work within existing systems as well as advocate for the expansion of other recruitment essential systems and system change need awareness. Nurse leaders must work collaboratively with human resource departments as well as becoming fundamental community recruiters in and outside of the work setting. (Anson, 2000, p. 21) This review of literature will then address general and specific issues of the role of nurse leaders as recruiters by thematically addressing certain trends and change needs in the health care industry in general and in nursing care that have specific and general implications in new nurse recruitment.

Nurse Leaders and Advocates for Incentive

It is frequently professed that the human element of any organization is its strongest asset, though restrictive budgets and a consistent multiplicity of need often take precedence over growth in staff personal development. In nursing care the emphasis must remain upon the patient of any institution, (Knox, Blankmeyer & Stutzman, 2001, p.45) which makes it important to make sure that this emphasis does not allow the institution to stray from seeking the highest quality employees to provide optimum care and therefore patient focus. The literature therefore stresses the importance of instituting a system to provide staff with opportunity and conditional monetary incentive to obtain higher levels of professional development. In this manner nurse leaders are made and these leaders with appropriate goals will recruit future nurses into the field.

Staffing is clearly one of the most important issues facing institutional care, especially in the face of a potentially exponentially growing health care industry. As baby boomers age, solutions to staffing must be core principles, as creating a base of invested and skilled staff is essential to sustaining new growth demands. In this demand to effectively staff, for the growing demand to come, there are many possible solutions. One of the most foundational solutions to high staff turnover as well as future recruitment and retention is to offer staff opportunities for professional and personal development, that will create investments equal to or greater than any expenditure on the part of the facility, with regard to recruitment of entirely new staff. In this manner nurse leaders serve a basis for demonstrative and philosophical leads in recruitment. In other words, those individuals in the medical care setting who have yet to achieve the status of RN or greater need to have the working opportunity to observe and even formally and informally interview RNs to help them determine the course of their future. This system could be in the form of a matched mentorship program, where an individual RN is matched with a staff member in the institution that wishes to explore nursing as an option. (Feldman & Greenberg, 2005, p. 80) Medical institutions employ people at many levels, from housekeeping staff to direct care aides. All of these individuals have the potential to develop into well informed and high functioning RNs as they demonstrate skills they have learned at lower levels of nursing care and those they obtain as nursing students. Programs and institutions that offer development incentives, therefore will foster and support the role of the nurse leader in his or her ability to help recruit good quality future nurses. The individuals recruited in this scenario demonstrate individuals who often have high levels of interest in the caring professions, a good bit of skill, and have simply not been given the opportunity to develop that skill and interest into realized high level licensure and education.

Healthcare institutions that offer incentive programs such as advanced development tuition reimbursement offer individuals a means to seek greater professional development, often in trade specific development and with the ultimate goal of continuity as contracts involved often include a retention clause, where the individual will commit to working for the healthcare organization after he or she achieves a higher degree for some period of time to "pay back" the institution for the investment. (Cimini & Muhl, 1995, p. 74) RNs and other nurse leaders are then offered a direct opportunity to influence individuals with interest and aptitude in healthcare to advance their degrees to the level of a nurse. This is a symbiotic relationship needs to be not only harbored as it exists today but expanded to improve the odds that those with interest and aptitude, that may lack opportunity are given that opportunity. Nurse leaders have the authority and responsibility to advocate for such systems in any institution they work.

One manner in which this can be achieved is to offer both time and conditional tuition reimbursement to current and future staff members, at both skilled and entry levels, so bilateral investment is ensured. Offering staff members the opportunity and time to seek adult professional development as well as conditional tuition reimbursement to do so can achieve a twofold result, one being that when seeking to retain or recruit employees the facility offers a nontraditional benefit that can be an immeasurable opportunity for many individuals and second will create a base of staff with greater skills to meet the ultimate goal of excellent patient care. Nurse leaders should be at the core of any such program as they demonstrate the most fundamental aspect of recruitment of skilled nursing staff through lived experiences.

Research and anecdotal studies illustrate that these unique support relationships in the nursing profession can endure for many years (Olson & Vance, 1993; Vance & Olson, 1991, 1998). Formal or planned mentor relationships are the organizational application of informal mentoring relationships. These relationships promote ongoing learning, excellence, and creativity in work, as well as commitment to the organization. Formal mentor pro- grams match mentors and proteges with respect to mutual goals and needs. These formal programs require careful planning, orientation, training, support, and follow-up of the participants (Vance, 1999; Vance & Bamford, 1998). Formal mentor programs provide heightened focus and visibility to mentoring, and create enhanced commu- nication, motivation, and productivity (Duff & Cohen, 1993; Kaye & Jacobson, 1995; Murray & Owen, 1991; Wickman & Sjodin, 1997). (Feldman & Greenberg, 2005, p. 85)

Given the nature of the facility, with its overarching emphasis on psychosocial care and the nature of the growth in information in this area, seeking employees who are capable and willing to seek out cutting edge development associated with such care could be the determinant factor of success. Making those employees from those who are already committed to serve this facility would be the best possible solution to any perceived shortcomings. (Zlotnik, Vourlekis & Galambos, 2006, p. 83) Conditional reimbursement frequently emphasizes time and success contracts that are best employed when the individual is offered support from the institution to allow growth. Forming a benefit such as tuition reimbursement contracts, often offered to employees with greater than one year of service to the institution, with an emphasis on achievement goals, such as grades above a certain level for reimbursement to be paid and a contract commitment to a certain number of years service following the completion of any degree or certificate sough and reimbursed by the facility. Such benefits packages have proven effective in many institutional settings, such as hospitals and prisons, in improving staff quality, recruitment and retention. (Wilkinson, 2002, p. 84) Simply employing such a tactic will help the institution emphasize an overall view of belief in the asset of the human element in its organization to current and future employees, to patients and families as well as to the broader community, which constitutes the future patients of the institution.

This step will also allow the institution to rightly claim that its overarching goal is to create a system that seeks out and builds the best staff it possibly can, reestablishing the medical industry as one that is progressively developmental, rather than a conglomeration of low paid entry level, dead end jobs. The importance of this message and the creation of a more progressive reality could make the difference between mediocre care and optimal care and environment for residents and staff. In short seeking to create an environment where employees are offered the opportunity to better their professional standing at every level will create a system that has far less burn out and turn over and emphasizes future rather than only immediate staff needs. The role that nurse leaders play in this is integral, as nurse leaders as they can fundamentally encourage those they mentor to better develop skills and education and help replace themselves as they age and leave their current positions. (NSSRN, 2007)

In addition to offering conditional tuition reimbursement the facility must also seek to allow staff time to achieve better outcomes with educational goals, including additional on site in-service time, staff communication time regarding educational endeavors and time off for educational attainment. Nurse leaders serve an interal role in this goal as they advocate for such services and even take the lead in administering and teaching on-site continuing education. (Feldman & Greenberg, 2005, p. 67) Staffing coordinators, often nurse leaders must seek to give priority to educational needs as a reason for adjusting and/or making schedules for staff, including offering incentives to staff not currently seeking educational goals for assisting in this priority regardless of the implementation of a tuition reimbursement program. (Feldman & Greenberg, 2005, p. 233)

Nurse Leaders as Academic Theorists

The fact that many nurse leaders serve as the fundamental sources for new and emerging nursing paradigms and theories cannot be ignored in this review. The theories associated with nursing are as diverse as nurses themselves and serve several purposes. With regard to nurse recruitment and the role that nursing theory and paradigm plays in it, nurse leaders serve to espouse theory through mentorship and training that helps individuals see their future intrinsic role in nursing. To explain this role a brief discussion of nursing theory will be conducted in this review of literature.

One of the most fascinating nursing theories that I have encountered as a student of nursing is that of Neuman. The literature associated both with defining the Neuman model and well as how it is applied in the modern illuminates the student to better understand the intimate as well as the global aspects of the system. The fascination, as a student is no doubt associated with the idea that the nursing model demonstrates an acknowledgement of not only the importance of balance within the patient's body and life but in the system itself. Additionally the theory or as Neuman states, "system" seems to best describe the support role played by the nurse that in some sense could be the determining factor as to whether a patient will recover, stagnate or worse, yet it does not seem to be adequately considered in the increasingly technical role of the nurse. Neumans Systems Model for nursing is a construct developed to explain the interconnected nature of personal variables and the prevention measures of the nurse to help the patient achieve a balance in his or her care and his or her life. To develop such nursing paradigms and apply them with mentors could serve to stimulate thinking with regard to how a future nurse might fit into this goal. (Heyman & Wolfe 2000, "Neumans System Model: Key Concepts")

The system is constructed of several parts, some personcentric and others environmental. The five "person" variables, as defined by Neuman are physiological; the structure and function of the body, psychological; the mental state and emotions, sociocultural; relationships, cultural expectations and activities, spiritual; ones spiritual beliefs and developmental; the process of development which occurs continually. Each person variable is interconnected and dependant upon the others which work in congruence to achieve balance. (Heyman & Wolfe 2000, "Neumans System Model: Key Concepts") When any one or more of these functions is out of balance the individual may experience stressors as well as, potentially ill effects, ranging from something as simple as a bad mood to the development of opportunistic infections, or debilitating chronic disease exacerbation. (Schneiderman, McCabe & Baum 1992, 1) Helping future nurses understand their role as a harbinger of a healthy, stress reduced environment will assist in the goal of the nurse leader to recruit future nurses with a purpose and paradigm that meets the needs of all.

The Neuman model is particularly helpful in its stress on balancing the technical aspects of nursing with the more social aspects that often drive individuals to become nurses. Holistic care is a current trend in nursing care, but it also brings to mind the real nature of nursing as a caring profession, a pull for many future nurses. In most nursing settings the focus of work is to actively heal the physical and therefore to focus almost entirely on this aspect of care. In the Neuman model this would be an irresponsible approach as it does not acknowledge the whole of the individual and his or her place in community. (Humphrey Beebe 2003, 67) (Timko 1996, 173) (Polivy & Herman 2002, 187)

The Neuman system theory is clearly an inclusive system, as it acknowledges nearly every aspect of the individual, and his or her environment. The system also acknowledges that the nurse has a specific role, not to facilitate healing, as this is clearly something the individual must do independently but to prevent additional stressors from affecting the individual, by controlling the environment and the input and output issues the individual is dealing with, while trying to restore balance. The role of the patient, to heal and restore balance and the role of the nurse are clearly defined, by the system and it is the job of the nurse to anticipate needs and opportunities for prevention. The system has even been applied to educating nurses and the education model of prevention as the roles of the nurse. (Peternelj-Taylor & Johnson 1996, 23) Stressing this model and others that work toward holistic nursing paradigms is an essential role in the nurse leader as recruiter. Those who already have intensive goals to continue in healthcare, with the proper support have ideologies that are based around real lived experiences of nursing and all medical care and seeking to employ these individuals as nurses will assist in building on the current goal and trend of holistic health care.

Neuman (1982) & #8230; recognizes nurses' claim to be concerned with phenomena relating to both client and environment. She identifies stressors originating in intrapersonal, interpersonal and extrapersonal areas. & #8230; she suggests preventive care and health education programmes, and that nurses should help 'individuals, families and groups' attain a maximum level of wellness (Neuman, 1980). (Sheppard 1991, 29)

The purpose of Neumans system, and other nursing paradigms, is to create a way of thinking about nursing that is more easily conceived by the nurse, so he or she may more easily go about the roles of protecting the patient from further stressors. Neuman attempts to create a context where nurses can easily understand the reasons for their actions, and anticipate the needs of the patient on a multifaceted scale.

Nurse Leaders as Educators

Nurse leaders have been sought as educators for centuries as nurse education is both clinical and experiential in nature. (Flynn & Stack, 2006) An expansion of the role of advanced practice nurses and other nurse leaders into credentialed roles and nurse educators is an essential aspect of the role of nurse leaders as recruiters of future nurses. There is a trend in "trade" education to recruit and allow many more individuals access to the role of educator, as hands on, real world training has become increasingly recognized as one of the most important aspects of trade education and essential to nursing education and recruitment. Sadly, in the field of nursing the role of educator has been frozen in many cases to include only those individuals with some clinical experience as nurses but mainly with advanced scholarly degree credentials. This is despite the fact that the roles of nurse leaders and Advanced Practice Nurses is expanding almost yearly. Resistance is in some ways scholarly and political as the role of educator in developed scholarly programs has always been limited despite the fact that many people in the world, without advanced scholarly degrees can and should be educating and recruiting future nurses. Many APNs in all the various specialties already do a great deal of education of patients, families and even some lesser nursing staff, such as MAs, CNAs, Med Aides, Pharmacy Technicians and others and do so effectively and with significant role insight to the whole scope of the needs of patients. APNs should be admitted to nurse educator programs to become nurse educators and should possibly also be given credit for clinical years served as a basis, regardless of the terminal nature of any clinical degrees that these individuals might hold. (Cleary & Rice, 2005, p. 133)

Current barriers exist for individuals with advanced practice clinical degrees and experience, ease of admission to programs that educate and train nurse educators. These barriers are legal, social, political and ethical but should be abolished, as such individuals offer exactly the needed ingredients for effective nurse recruitment and education roles, as they offer both scholarly but mainly real world experience that can then be a great asset to the classroom ad should be acknowledged without prejudice.

Advanced practice nurses such as nurse practitioners are often thought of as clinical nurse specialists. They are capable of developing patient care models and treating patients in many settings, in some states independent of physicians while in others as what would be though of as an assistant to a physician, supervised by a physician in a clinical setting. APNs are a group of highly trained and well educated medical professionals often with many years of clinical experience, but often with degrees in nursing that are in a scholarly sense considered, terminal degrees or degrees which cannot be built upon but require a complete restart of advanced degrees (Masters or Doctoral) to add credentials that would allow these highly skilled individuals to choose a course of action such as nurse education. The same can be said of Certified Nurse Midwives as well as Nurse Anesthetists, Family Nurse Practitioners, Psychiatric Mental Health Nurse Practitioners, Clinical Nurse Specialists and many other titled and certified APN roles. Additionally in most cases these APNs also serve as educators to some degree if it is only in the role of the patient/family educator and expanding this would not seem odd. (Mccabe & Burman, 2006, p. 3) APNs would be a great asset to the nurse education system, as they offer the perspective of many years of clinical and personal experience with patients that might be limited to an individual who has been historically an academic nurse educator.

The evolving role of Advanced Practice Nurses (APN) has been in near constant ethical, legal and legislative debate since the early inception of advanced degrees in nursing, but is always of particular interest during times of economic duress in the medical industry and specifically it should be discussed when the need arises for more cost effective ways for skilled nurses to seek to advance into education. As is stated by the author of the work Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing written in 1992 by Barbara Safriet, some of the economic stress being experienced by health care, and most importantly the health care consumer can be solved with a greater emphasis in the "health care industry" on developed and coordinated utilization of the APN as an APN is a competent health care provider who is capable of providing equal (and possibly better) care to consumers for a better price. Safriet then goes through a lengthy description of legal and economic restrictions that have been placed upon the APN role as a result of the desire to retain control, by physicians and limit the scope of APN care to minimal provision. Additionally, Safriet provides ample evidence that these restrictions on care unduly limit the caring role that APNs can take in the broader design of the disorganized and misdirected health care system. (Safriet, 1992) To support the role of the nurse leader as educator and recruiter an expansion go education opportunities for APNs is essential.

Safriet explains that the "health care" community is largely a misnomer as the emphasis in the community has been not on health or care but on medicine and biomedical research, neither of which equate to health or care and both of which are sapping the system of needed resources for actual care provision. The work is detailed and fair in its assassination of allopathic care as an institution heavily slanted toward "heroic" measures and measures that could make life saving care even more cutting edge with each patient. Yet, individuals in the community may see this trend as damaging, as an outside view, offered by potential future nurses stresses that the role of health care is far larger than to treat disease. This outside largely, "jaded" view negatively impacts the recruitment of future nurses, and nurse leaders need to be a part of the re-illumination of the goal of nurses in a broader context that more closely resembles a system of "health and care."

Using the 1995 Nursing Social Policy Statement, APNs are defined by the advanced clinical practice knowledge and skills they possess relative to their area of specialization. Specific defined functions within the advanced practice include formulating differential diagnoses, managing acute and chronic illness through both pharmacologic and nonpharmacologic means, coordinating care, promoting health and wellness, and applying clinical reasoning skills (Donagrandi & Eddy, 2000; Fitzsimmons, Hadley, & Shively, 1999; Sebastian et al., 2000). (Burgener & Moore, May-June 2002, pp. 102-103)

APNs can therefore specialize in several different areas of care as well as practice and direct care specialists, such as is the case with Nurse Practitioners. What is most important is that these providers are more grounded in their approach to medical care, seem to be more idealistically focused on a continuum of care and provide their services for lower costs that do physicians and other higher ranking care providers. As such, theses nurse leaders are an essential link in the role of recruitment.

Added to this already impressive list of APN attributes are the additional roles of mentor, consultant, researcher, and educator, all of which contribute to the larger domain of professional nursing while supplementing the clinical practice role requirements (Fitzsimmons et al., 1999). (Burgener & Moore, May-June 2002, pp. 102-103)

The purpose of the APN role is varied and wide, given that the role itself in any individual situation can serve a variety of settings and specialties, in accordance with and absent from a general practice role as an independent care provider for acute and/or long-term treatment. The need then to advocate for recruitment roles is essential, and all APN trade organizations should be actively seeking to train their APNs as recruiters not only of APNs but general nurses, at both the RN and LPN levels.

The nurse practitioner and the training agents must be aware of the complicated nature of medications, what they do and what the symptoms of interactions are as well as the symptoms of non-compliance, a frequent issue in chronic care medicine. These same APNs are then in a significant position to aide in teaching general nursing and advanced nursing care issues. Additionally, the role of the APN, nurse practitioner in care is significant in the development of patient relationships that are more akin to the role of the nurse as nurturer, as the separation of the practitioner (by authority) is a constant struggle in chronic care, as any illness is an exceedingly personal experience requiring significant emotional connectivity. Teaching this additional role continually through the classroom and the clinical setting is a strength of APNs as nurse educators. (Levin & Feldman, 2006, p. 126) Ethically speaking the APN is a significant partner in the development of nurses who are more responsive to the ethic of care and the community must stop thinking of APN degrees as simple professional licenses (Adams, Ekelund & Jackson, 2003, p. 659) as such experience should be viewed as crucial to advancing nurse education and the ethical aspects of nursing.

Continuing with the status quo, with the nurse educator as the scholarly teacher and the clinical nurse as the clinical teacher would likely be an easy course, yet recruitment questions for future nurses would not be effectively answered as clinical as well as theory are essential to new potential nurses identifying the whole scope of the role they will play.

As an APN the message and knowledge of these sentiments are essential and demonstrative of the serious need to address, advocate for and redevelop the "system" that is so highly focused on biomedical research and heroic medical intervention and on maintaining the scholarly/clinical barriers that currently exist in nurse education and recruitment. The health care system needs to redirect energies toward moving away from litigious thinking and stepping toward a continuum of care that pays much more attention to all three aspects of care; access, quality and cost. As an APN (nurse leader) lobbying for change and altering directive care in the system is something that can be applied on an every day basis to help address these concerns, and possibly redirect the mentality of the care system to one that better meets patient needs, rather than focusing all the resources on programs and mentalities that are heroic, extreme and in some cases not really sensible for long-term care, especially with chronic or natural conditions of health, disease and wellness. Recruiting new nurses with these objectives in mind from the onset will add to the essential strength of the role of nurse leaders in recruitment of new nurses at every level.

Recruiting in Special Populations

Nurse leaders are also important in recruitment of individuals of minority status. It must be acknowledged that institutional racism is present in health care. Nurse leaders can serve as an integral force in recruitment of minorities to education and employment retention in the nursing field, in nursing this includes racial minorities as well as men. The face of institutional racism includes limited minority employment, i.e. seeking, education and hiring individuals for health care employment who are almost exclusively of the majority. This divide furthers the separation of disenfranchised minority individuals from those who provide care. The professionalization of nursing, a largely female position (Daly, Speedy, Jackson, Lambert., & Lambert, 2005, p. 26), as well as increased numbers of women and minorities in higher positions in healthcare have helped the situation but with the constitutional elimination of affirmative action in education this progress may well be short lived. ("Influx of Women Doctors," 2008, p. 34) Though the nation is stepping away from affirmative action, the health care industry should still be paying attention to diverse recruitment through other means whenever it is possible and in every community. (Antwi-Boasiako & Asagba, 2005, p. 734) Nurse leaders can and should advocate for the elimination of institutional racism by seeking to recruit diverse populations.

The experience of nursing is a highly personal one and nurse diversity is essential to helping institutions and the system in general meet the needs of an increasingly diverse patient population, not to mention that minorities are seen in higher numbers in health care because institutional racism supports fewer opportunities and lower levels of health knowledge and attainment by minorities in the broader society. If, for instance translation is not available on the nursing floor, most specifically with the availability of bilingual nurses many circumstances of communication breakdown occur, and so frequently that conflict, fear and breakdown become part of the atmosphere for every nurse and every patient. Facilities must be aware of this need and answer it to meet the patients' need and nurse leaders need to advocate for diverse recruitment and then take part in it. If the nurse must call for a translator, who is not in the nursing industry and then wait for such services to arrive for an hour or even longer, precious time can be lost and the patients' needs might not be met, or worse the patient can be put in danger of falling, or not following the orders needed to maintain and facilitate healing. If this occurs the culpability is evident and the development of care is lacking. (Agency for Healthcare Research and Quality, 2003, website)

The ideas associated with cultural competency are clearly well intended as they make every attempt when met to meet the needs of culturally diverse populations, yet without direct in-house and trained institutional interpreters and other services that are specific to areas other than linguistic differences they are simply a good idea. Nurses in particular should advocate for human resource attention for culturally diverse recruitment and hiring, at all levels (as many individuals such as dietary aides, CNAs, facilities maintenance providers and others can assist the nurse and patient in a better understanding of each others needs) and nursing organizations should continue seek to lobby for the recruitment of culturally diverse students. Though the nation is stepping away from affirmative action, the health care industry should still be paying attention to diverse recruitment through other means whenever it is possible and in every community.

Cultural competence is therefore a very responsive and positive current trend in health care to establish systems that are much more open and receptive to cultural diversity and the particular needs of a culturally diverse regional and patient populations. Culturally competent is the designation that is utilized to describe a health care facility that answers the needs of a diverse population through services and employee/volunteer recruitment and training that recognizes cultural diversity, assists cultural minority individuals through specific important access points, and services to achieve a better patient outcome, overall. The overall theory of cultural competence designation works well with the impetus nursing based theory, developed in the 1950s by nurse and anthropologist Madeleine Leininger, Transcultural Nursing Theory. The definition of this theory, according to its founder is; "a legitimate and formal area of study, research, and practice, focused on culturally-based care beliefs, values, and practices to help cultures of subcultures maintain or regain their health (well-being) and face disabilities or death in culturally congruent and beneficial caring ways (Leininger, 1970, 1978, 1995)." (Leininger, 1999, p. 9) Leininger also developed a framework associated with Transcultural Nursing theory, known as the Sunrise Model, which illustrates the theory and will later assist with the development of an in-service model for use in a psychiatric care setting, among psychiatric specialist nurses.

Within the framework of Transcultural Nursing Theory is the basis for the standard of creating cultural competence in every corner of health care, with a particular emphasis on nursing care and a serious need for such care to transpose that of psychiatric nursing. Nurse leaders in psychiatric care as an aspect of recruitment of new nurses must then pay particular attention to cultural diversity in hiring and cultural competence in mentorship. Psych nursing and psychiatric care in general is a seriously challenging field of practice and study. Transcultural emphasis is also particularly important in psychiatric nursing as psychiatric disorders are frequently aided by positive cultural experiences, and exacerbated by the confusion associated with cultural divergence. In other words for psychiatric care patients' cultural disparity challenges their fragile state to an even greater degree. Additionally many of the negative connotations associated with psychiatric illness are culturally born and therefore require recognition and possible intervention to alleviate. With the development of a Transcultural model for recruitment and continuing education many psych nurses would be seriously aided by furthering their understanding of how culture plays a part in the health and wellness of a psychiatric patient and a community and how they could use such knowledge to build a better care ethic with regard to cultural competency.

To better understand how cultural competence works in a broader setting one must understand the medical model of cultural competency, as it is employed by the medical industry. The standards are often based upon those associate with the Office of Minority Health. This functional group puts forward a list of 14 standards that are either mandated or strongly suggested that are collectively present for an institution to be deemed a culturally competent provider. The standards are known as Culturally and Linguistically Appropriate Services (CLAS) and encompass a set of rules that guide systems to meet the needs of the community the institution may serve. Though it is clear that many institutions simply focus on levels of services for commonly found minorities in their given community, some, especially hospitals and psychiatric institutions and especially those in urban settings focus on large numbers of minority cultures, to develop and establish culturally competent designations. The resulting procedures and manuals are also foundationally focused on the assumption that for the most part the nursing staff and others will use common sense and respond appropriately, even when they do not necessarily know what to do. In other words manuals and training materials often assume that those they are responsible for training have a stronger grasp than they actually do with regard to cultural awareness. Recruitment within and outside of healthcare on the part of nurse leaders must then fundamentally address the knowledge base of cultural competence.

The 14 CLAS standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations" (U.S. Department of Health and Human Services, 2007) (1) This work will briefly overview four of the 14 that are mandates, as designated by federal requirements and the three initial standards designated as culturally competent care standards. Though, it is increasingly important that even the recommendations of CLAS be met, in much the same way that disability accommodations are met, gradually through time and with intent. This is especially true when an institution is considering human resource strengths and weaknesses in culturally competent care objectives. A review of resources or culturally competent care audit could serve to better develop the needs of any particular institution, community and education system in recruitment of diverse populations and particularly in the recruitment of nursing staff by nurse leaders in and outside the institutional setting. As has been stated previously institutional racism is at play in a broad sense all over this society and those individuals of minority status, may be at a greater disadvantage than others with regard to opportunity. This is observed in a staff audit which clearly shows in many institutions of health care that diverse populations are more demonstratively employed at lower levels in the institution, populating housekeeping, tech staff, maintenance and grounds crews, dietary staff, CNAs and MAs than they are populating the higher function fields, such as in skilled nursing and other higher ranking staff. To better illuminate the concepts of CLAS one must look at least briefly at the seven distinctions:

Standard 1 Health care organizations should ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

Standard 2 Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.

Standard 3 Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4 Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5 Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6 Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. (U.S. Department of Health and Human Services, 2007)

Though there are several more identified standards according to OMH, these seven demonstrate the core of the demand for cultural competency in health care. In the health care setting the provision of these standards is either strongly suggested or mandated if they receive certain types of funding, which most institutions do. Collectively these mandates being met define the designation of culturally competent care. As has been noted before, the standards even after having been met do not specifically focus on a dominant regional culture or offer the institution and its staff any specific cultural awareness or understanding.

It then becomes the responsibility of the institution, beginning in many cases with the nursing staff to focus specific attention on dominant and rare cultural awareness, which may very well mean interviewing and researching culturally diverse individuals as they are seen in the setting. Recruitment of or advancement of individuals in nursing or other positions who have specific knowledge of a given culture the nurse or other staff is seeking to care should be an essential goal of the nurse as leader. With regard to specific populations one must look first and majority minorities and the awareness of their needs but then this must be expanded. (Yurkovich, 2002, p. 147) In other words to retain cultural competency institutions cannot continue to focus singularly on the Spanish speaking immigrant populations but must also expand capabilities and knowledge to other groups.

The standards of cultural competency that are met by almost all medical institutions are clearly those that are designated mandates by federal guidelines, (4, 5, 6, 7) which are all focused on linguistic access with a very limited emphasis on the social, cultural and religious aspects of cultural diversity. Hospitals, in fact sometimes seem to think of cultural competence as a designation of signage and interpretive service access, that is available for most of the working day, but not necessarily at all times. Clearly, the question of cultural competence is much more than language. On a socio cultural level providers and individuals within the system must not be left wondering if cultural issues that might need to be addressed, for any given individual, beyond the linguistics level are available and/or in need. All facilities, except the most diverse in and of themselves and therefore advanced in cultural care opportunities would benefit from a cultural competency audit, as noted by Georgetown University's National Center for Cultural Competence, to both determine the needs and identify hidden strengths in a system. (Georgetown University Center for Child and Human Development, n.d.) Nurses in an institutional settings are among the most important advocates for patients, as they tend to be those with the highest number of direct contact hours to patients and therefore their needs, culturally and otherwise. If a nurse is made aware through this contact that cultural issues need to be addressed for any given patient then they are in the best position to advocate for such intervention and potentially to recruit with this in mind.

Another pressing issue of cultural competence that must be addressed in many institutions has to do with the intricacies of direct patient care. Nursing care is a very personal aspect of care and any given nurse interacting with any given patient might have difficulty dealing with the impact of suggestions for nursing interventions and/or psychiatric care provision if cultural needs are not being met, linguistically or otherwise. (Hatton, 1992, p. 53) Without the demand for services associated with linguistics or faith even the nurse may never know that the individual is reluctant to follow nursing or doctor's orders because they are incompatible with cultural beliefs. In these situations, the worst possible situation is the creation of an impasse between the nurse and the individual, as neither understands why each is asking for or acting in a certain way and therefore non-compliance ensues. (Heuberger, Gerber & Anderson, 1999, p. 107) A simple linguistic intervention might solve the problem, of the impasse and allow the patient to be clearer on the benefit of orders. If there is no way for the nurse to quickly communicate directly with the patient the nurse and patient are left feeling as if they have no ability to act effectively to facilitate good patient outcomes. Mutual understanding on both parts is broken down and can create problems of health risk and even risk patient and staff physical safety. Nurses recognize that patient must do things to achieve health that are contrary to anything they do normally in their own element and yet if the nurse is unable to communicate this need and its importance to the patient is left at risk. In many cases the family of the patient is relied upon to stress the importance of any given order, but this cannot be the exclusive job of the family, especially in the psychiatric facility and many families have only limited if any access to the healthcare setting. Though their goal is to support the individual and this is clearly contrary to orders, that they might not even fully understand, as most people have little if any medical background and even fewer have psychiatric care knowledge, they could become liability rather than asset to patient care and might then have even less access to the patient to assist the patient and staff in better serving the patient, culturally. One particular case that happens to involve a situation with a patient of Russian decent describes the differences between qualified and unqualified interpretation, where the family, in this case the son was incapable of translating medical terminology and concepts to the patient and the patient had a negative outcome as a result, defines the need to expand institutional capabilities, with other cultures. (Office of Minority Health, 2001, p. 73) An additional example in the same document the 2001 final report on CLAS competencies there was an Asian family who was resistant to autopsy, as a result of cultural issues and was therefore alienated by staff by their insistence of the service. (Office of Minority Health, 2001, p. 107) The autopsy, in this case could have furthered the understanding of the disorder and/or disease tat the individual died of and therefore improved the chances of better treatment for others in the future. Both of these examples bring to mind the necessity to expand cultural competencies, and recruit diverse future nurses.