Development of the Korean Nursing Profession with Changes in its Legal Basis

Background: To identify howthe self-regulation and specialization of nursing have changed with nursing-related legislation, the Medical Service Act in South Korea and factors influencing these changes. Method: We conducted a systematic analysis of nursing-related legislation and a literature review to identify how the nursing profession has developed with legislative changes. Results: We identified four main categories of change innursing self-regulation, along with the background leading to these changes and their subsequent impact on the policies of nursing education and practice. Those four categories were “nursing licensure,”“scope of nursing practice,”“self-regulation by professional nursing association,” and “accreditation of nursing education programs.” Conclusion: Our summary of the notable revisions in the Medical Service Act and various bylaws can help to identify their socioeconomic, cultural, and environment impacts on nursing professionals’ advancement. Development of the Korean Nursing Profession with Changes in its Legal Basis Publication History: Received: October 15, 2015 Accepted: January 30, 2016 Published: February 03, 2016


Introduction
What kind of care should patients expect of nurses?Although this is a very simple question, it has a complicated answer: quality nursing care is dependent on a number of factors, such as nurses' education, licensing requirements, competencies, and professional self-regulation, which are all governed by various governmental policies and legislation.
The demand for nursing personnel has increased in South Korea with the tremendous socioeconomic development and improvement in quality of life [1].As a consequence of the development and consequent fragmentation of health services and technological advancements,the traditional roles of medical doctors have been divided between various healthcare personnel.In particular, the nursing profession has changed significantly compared to the previous century, when the first missionary doctors and nurses introduced westernized healthcare services to South Korea.Societal changes, war, and changes in politics and legislation have forced thenursing profession tochange its practices and education as well as the title, from Kanhowon to Kanhosa [2,3].
To envision the future directions of nursing,we must understand how its legal basis has changed.A particular focus would be on selfregulation, which refers to the ability for a profession to control its own personnel admission, requirement standards, and practice norms [2].In South Korea, the nursing profession hasa long history since those aforementioned missionary nurses shared their nursing knowledge, skills, ethic, and philosophy of nursing more than a hundred years ago [4].Thus, a review ofthe improvements innursing in South Korea in terms oflicensure requirements and nursing competencies will guide researchers in devising a strategic plan for future advancement.
The purpose of this study was to identify how the self-regulation and specializations of nursing have changed with related legislation.Furthermore, we examined the historical background of nursing laws, conducted an evaluation of related systems, and clarified the significant contributors to changes in nursing legislation.

Research design
We conducted a retrospective literature review on legislature related to the nursing profession and its self-regulation to clarify how this profession has developed.

Data collection methodology
We retrieved all iterations of the Medical Service Act and legislation on nursing self-regulation from the database of the Ministry of Legislation.We retrieved the reason for the formation of a given piece of legislation, any revisions made to it,its history, and its enforcement date.

Research procedure
To select the key factors affecting nursing, all articles of the legislations retrieved were grouped by their responsibility and authority.Then, we verified the impacts of each legislation on the nursing profession via a literature review.

Review of legislation
History of Medical Service Act, its enforcement decree, and rules Reasons for promulgation and revision of legislation Identification of articles related to nursing Profession Grouping according to contribution to self-regulation of nursing Nursing licenses and related regulation Scope of nursing practice Self-regulation byprofessional nursing association(e.g., supplementary training, reporting, and ethics) Accreditation for nursing education

Literature review for verification
Literature review for verification Historical review articles Books on history ofnursing profession

Scope of reviewed iterations of Medical Service Actand its reason for revisions
The first iteration of the Medical Service Act, called the Nation's Medical Service Act (NMSA) was promulgated on September 25 and implemented on December 25, 1951 [5].Article 2 of the NMSA designated three types of healthcare personnel: (1) doctors and dentists;(2) oriental medicine doctors; and (3) public health nurses, midwives, and nurses.The various iterations of the Medical Service Act and their enforcement dates are shown in Table 1.

Nursing licensure
Historically, nurses in South Korea have been licensed by the Ministry of Health and Welfare.However, supervision of licensing examinations was controlled by local governments rather than the central government (as it would be withother healthcare personnel, such as doctors, dentists, and oriental medicine doctors) [5,6].To apply for the licensing examination, applicants must be enrolled in a specific nursing school or must have a foreign nurse license after graduation from a foreign nursing program.
After the Medical Service Act was overhauled in 1962, it took approximately ten years to achieve integration of the license issuance with the national examination under the soleauthority of the Ministry of Health and Welfare [7].In 1988, a national licensing examination was developed for midwives, and overall management of licensing examinations was delegated to a professional institute whose sole purpose was to conduct national licensing examinations.
Recently, amajor change to national licensing examinations was announced publicly: specifically, it dictated that only applicants who enroll in nursing programs accredited by the national education board can take the national licensing examination.The article of the Medical Service Act detailing this issue was announced in 2012, although it will only be enforced in 2018 [8]. a member of the United States Operations Mission to Korea.In Dr. Adams report, he pointed out the importance of shifting from taskoriented nursing with lower-level entrance requirements for nursing schools to practice-oriented nursing via implementation of a nursing licensing examination [9].The Korean government accepted and applied Dr. Adams's recommendations in a major nursing policy to improve the quality of nursing education.Since this historic moment, management of the national licensing examination has been taken over by a specialized national licensing examination institute [9].This reform was enacted because the Ministry of Health and Welfare understood how essential nurses are for a healthy workforce, which in turn is necessary for national prosperity.Another important change was make it a requirement for nurses to regularly report their current employment, which can aid in effective planning of the national and local healthcare workforce to best meet communities' needs.

Scope of nursing practice
The scope of nursing practice was originally limited to care of injured or sick people and assisting with medical treatment (according to Article 1of the Enforcement Decree of the NMSA in 1951).These duties remained in the enforcement decrees of the 1962 and 1982 iterations of the Medical Service Act [10]; however, the 1982 iteration widened the scope to its current form, where in nursing practice also includes care of postnatal women and conducting health activities as prescribed by the Presidential Decree.
The scope of practice for different nursing specialties was defined for the first time in 1973 via a ministerial decree.At this point, only three specialties were recognized: public health nurse, nurse anesthesiology, and mental health nurse [11].In 1990, two more specialties were added: nursing assistants and homecare nurses.At present, there area total of thirteen specialty areas defined by various enforcement decrees.
Our analysis of legislation on the nursing profession revealed South Korea's socioeconomic development plan and its effect on nursing.After Korea's liberation from being a Japanese colony in 1948, the Korean government created its first constitution.However, just two years later, in 1950, the Korean War began and lasted for over three years.In the after math of this war, the Korean government focused on reconstruction and economic development.During this time, nurses were exported as a labor force to Germany so that the government could obtain financial loans.
Nurses' immigration to Germany led to a greater understanding of the differences in nursing education and nursing organizational culture between South Korea and Germany [12].When this immigration ended in the mid-1970s, nursing personnel policy in South Korea had changed extensively, with the most notable change being the establishment of a nursing assistant system [12].supplementary training; furthermore, astronger punishment possibility of license suspension was added.
In terms of self-regulation of ethical issues, since 2012, there has been greater regulation of ethical committee activities by the central nursing association, and it is now requisite for healthcare institutions to ask the Ministry of Health and Welfare for suspension of a nurse's license to avoid under mining nurses' dignity [14].Besides these self-regulation activities, the word for nurses was changed from kanhowon to kanhosato improve nurses' social image and ensure that they were afforded the same respect as doctors [15].The Korean word for nurse was originally kanhobu, with the ending bu meaning housewife, therefore it was replaced by kanhowon, designating professional or technical statusced in 1945.In response to Korea's sociocultural effects, the word for nurse was reformed to kanhosa, with the ending 'sa' connoting teacher, because ending words 'sa' referred to professionals as in uisa for doctor, yaksa for pharmacist.All of this word change was possible with the first Asian president of International Council of Nurses, Dr. Mo Im Kim's support to change societal recognition of nursing [16].
The self-regulation of the nursing profession was achieved with the delegation of registration, monitoring, and discipline of nurses to an autonomous professional organization by the central governmental.This organization has helped in ensuring delivery of quality nursing services to the general population [17].The Korean Nurses Association was founded in 1923 and has seventeen regional chapters and ten affiliated organizations, including the KABONE.The Korean Nurses Association is committed to upholding Korean nurses' social positions and building nursing professionals' competencies.It developed its first code of ethics in 1972, which has been subsequently revised to the level of global standard [18].
Regarding the expansion of nursing practice, Dr. Mo Im Kim had a vision of a global-oriented humanistic approach to nursing practice.She placed particular emphasis on the necessity of public health nursing and has created a number of training programs for the same.Ultimately, her efforts contributed to the enactment of legislation on special measures for public health and medical services in agricultural and fishing villages [19], and revision of the Medical Service Act to include the specialty of community-based home care nurses.This community health practitioner system has become a critical element of the public health workforce in remote areas [20,21].Specifically, because there was a shortage of nurses domestically in the late 1960s, the government created the position of nurse assistant to ensure a supply of substitute personnel.This nursing assistant system had its benefits and faults, with the most notable fault being a scope of practice that was limited to assistant activities.However, future ministerial rules enlarged nurse assistants' scope of practice to assisting in medical treatment, which has, unfortunately, resulted in a long-lasting problem of malpractice issues.
Nursing education was further developed in the 1970s, with the first doctoral program appearing in 1973.Furthermore, the Bachelor of Science in Nursing became the standardized entry-level education for nursing.This standardization was headed by Dr. Mo Im Kim with the assistance of her nursing mentor, Dr. Adams, and began in the mid-1960s.When Dr. Kim was a congress woman and committee member for health policy in the Korean National Assembly, the Korean Nurses Association organized an open public meeting to devise a legal basis for nursing education since 1980's [13].Since then, the Korea Accreditation Board of Nursing Education (KABONE) was established in 2001 and subsequently approved by the Ministry of Health and Welfare of Korea in 2004.

Self-regulation by aprofessional nursing association
The formation of a professional nursing association was mandated by the enforcement decree of the first Medical Service Act in 1951.This act also allowed the Ministry of Health and Welfare to provide short periods of training and conduct research at its owndiscretion.In 1982, an ordinance of the Ministry of Health and Welfare required the nurses' central association named the Korea Nurses Association to implement supplementary training programs as required to improve the competencies of its members.
Another duty was enforced in 1965: namely, nurses had to begin reporting their current state of employment and licensing [13].Later on, in 2012, this duty was modifiedby addingan article mandating that nurses' reports are to berejected if they have not completed

Figure 1 :
Figure 1: The study procedure for investigating changes in legal basis of the nursing profession.
The nursing licensing examination was initially directly controlled by local governments, but ultimately came under the supervision of the central government as a result of Dr. Mildred Adams' summary report on nursing in the Republic of Korea.Dr. Adams was an advisory board member of the Korean Ministry of Education and Kang SJ, Kim IS (2016) Development of the Korean Nursing Profession with Changes in its Legal Basis.Int J Nurs Clin Pract 3: 165.doi: http://dx.doi.org/10.15344/2394-4978/2016/165 Int J Nurs Clin Pract IJNCP, an open access journal ISSN: 2394-4978 Volume 3. 2016.165Citation:

Table 1 :
Reviewed Acts and Enforcement Dates.

Table 2 .
Nursing licensing issuance and examinations by article of the Medical Service Act.