On September 3, 2009 I had the pleasure of spending most of the day with the president of the Korean Nurses Association and her sister. They were in New Mexico to see Dr. Kyung-Rim Shin's son, who is studying at the UNM School of Medicine, and Dr. Shin was interested in the regulation of nurses and especially advanced practice registered nurses (APRNs) in the United States. In Korea they do not have a Nursing Practice Act or a Board of Nursing that regulates the practice of nursing, nor disciplines nurses. Many nurses work in little 10 bed hospitals owned by physicians, however there are also huge medical centers where nurses work. Dr. Shin is on faculty in the nursing program at Ewha Womans University in Seoul, South Korea. Founded in 1886 by Mary F. Scranton, an American Methodist missionary, Ewha (Pear Blossom Academy) began offering college courses in 1910, professional courses in 1925, and in 1945 was granted University status.
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Dr. Shin was very impressed that in New Mexico nurse practitioners and clinical nurse specialists have independent practice and independent prescriptive authority, that some of the advanced practice RNs had their own clinics or practices and saw patients/clients without the oversight of physicians. By the end of our afternoon together, Dr. Shin had asked if I would be interested in coming to Korea to discuss with nursing leaders how advanced practice nurses practice and are regulated. It was only after I had said good-bye to her that I had time to read the Korea/English folder she'd given me that describes the history of the Korea Nurses Association (KNA), the involvement of KNA leaders in the International Council of Nurses, and the advanced nature of education in Korea.
In October I was invited to speak at a conference in December, so quickly renewed my passport and began developing power point presentations. Because each presentation was going to be translated into Korean and published for the participants, each slide had to be very detailed, so I spent a lot of time on the internet looking up NP, CNS, CRNS and nurse midwife salaries, checking with colleagues on costs of professional liability insurance, and reviewing the nursing practice act here and in other states for just how regulate APRNs.
I have not traveled outside the United States before, except for 7 days in Mexico for a medical conference/vacation twelve years ago, and my knowledge of Asian cultures is woefully lacking, but I got on a plane and traveled for about 24 hours straight to arrive in Korea. Met by a delegation of the Korean Nurses Association, I was whisked away to my hotel, where I was allowed to drop my bag in a suite and then taken to a 10 course traditional Korean feast with even more leaders of nursing. I was introduced to favorite foods of the Koreans, including Kimchi, a fermented cabbage/Korea pepper sauce dish (HOT), that I think was offered to me at least once a day after that first introduction. I even tried, despite my reputation as a picky eater, dried anchovies (salty and very slightly fishy, but crisply crunchy).
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I was assigned two "handlers," Donghee Lee, Master in Education, Director of Department of International Affairs at Korean Nurses Association, (BSN Indiana State University, RN in US, awaiting licensure in Korea), and Sang-Hyup Park (BA in Economics at UNM, now working under Ms. Lee). These two young people were with me every time I left the hotel, taking me shopping, sight-seeing, to the bank to change American Express traveler's checks to won (their currency), to lunches, dinners, and cultural performances. They explained health care, education, traffic, and society to me in gentle, friendly ways. Sang-Hyup was assigned to carry my purse and shopping bags every where we went, and did it with grace and without embarrassment. Donghee Lee became my friend and nursing colleague over the four/five days I was there. They took me shopping in a traditional shopping district (oh, it is so COLD in December in Seoul), to a 1000 year old palace, to a Buddhist temple, and to a nine-story tall department store ... departments is correct--on the women's clothing floor there were sections for Dolce and Gabbana, Versace, Donna Karan, Dior, etc.
Seoul is amazingly high-tech. Everyone has at least one cell phone, all with little dangling charms hanging from them with traditional Korean endless knots. You cannot hear other people's conversations--they talk with one hand holding the phone to their ear, the other covering their mouth. The traffic is challenging (10.5 million people in the area of 3/4 of NY City), but the city has traffic monitoring devices in all intersections, the taxis and buses, and even private cars have sensors in them so that as traffic slows, Dept. of Transportation workers can re-route traffic approaching the slow-down to take alternate routes by re-programming the GPS turn-by-turn devices. The citizens have turn-by-turn in their cell phones, which they put up on the dashboards for the same purpose. Their cell phones allow them to watch TV programs live, look up translations of words and phrases, and so many more applications that I've never seen here in the U.S. I never saw anyone pay with cash, although I am sure some do--everyone uses credit cards for taxis, tea, meals, everything! They have a system in Seoul for public transportation, where you carry one of many designs of radio frequency tokens on your keys, your phone, in your pocket. Depending on how far you ride and whether you have multiple transfers to get around the city, the Dept. of Transportation deducts a small amount from the balance on your token. They can tell if you are following your usual pattern for getting to work, and if there is a large ridership that morning, add more buses or subways to accommodate the riders. The people of Seoul don't even realize that all this is going on--when I told Donghee and Sang-Hyup about the video I'd seen on the plane about the system, they were amazed ... they grew up with it, and didn't realize all that went on behind the scene to make commutes as smooth as possible.
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Advanced Practice Registered Nurses (called nurse practitioners in Korea) do work as midwives, anesthetists, and clinical nurse specialists. At the conference, titled, "Development of Korean Nurse Practitioners' System through Cases in the United States," a 3rd level nurse practitioner described her practice as an oncology nurse practitioner, discussing her role of recommending, and managing patients receiving stem-cell transplantation. It sounded like she works in large hospitals working with family practice doctors who are not particularly familiar with the benefits and risks of stem-cell transplantation. Apparently nurse practitioners do not, and are not allowed to, practice independently or have prescriptive authority, nor serve as primary care providers. So the term nurse practitioner in Korea is more closely aligned with the clinical nurse specialist role of APRN than the U.S.'s role of nurse practitioner. The faculty at Ewha Womans University had many questions about authority to practice, what it cost to open a practice, how nurse practitioners were able to get insurance payments for seeing patients, and how the income of nurse practitioners compared with that of physicians.
I didn't have an opportunity to discuss with the KNA leadership more on the education of nurse practitioners after the conference. The conference raised a number of questions in my mind about licensure, because the Korean Accreditation Board of Nursing apparently reviews the transcripts of all RN candidates by May 1 of each year, and determines whether they are qualified to take the licensing examination, but after that there is apparently no control over the licensees. Ongoing education is expected--most of the nurses I met were doctorally prepared, many had Master's degrees, and the oncology nurse practitioner had a doctorate, so apparently becoming a nurse practitioner is through education without further certification or licensing. I certainly have more to learn about professional nursing in Korea.
Although I didn't have an opportunity to visit one of the small, privately-owned "hospitals," run by physicians for their own patients, Donghee and Sang-Hyup took me for a tour of Yonsei University Hospital, a 2,224 bed facility with 42 very busy clinics, and educational departments spread out over a large campus. The facility was beautiful with marble entrances, patient rooms for 1-5 persons, plus a lounge chair for each patient's family member who helps to feed, turn, toilet, walk, and care for their patient. They have the latest high-tech gizmos, and provide excellent care. Each staff nurse on a Med-Surg floor will have 8-10 patients assigned to them, but patients stay in the hospital for at least 3 days after an appendectomy, 2-3 days after a vaginal birth and so forth; and the family member is there to help with their care. There isn't all the churning of admission, procedure, and discharge in 24 hours, so the nurses actually have time to educate the patient and family, and insure on-going care at discharge. I didn't see one stressed-out, frantically busy nurse in the University Hospital.
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Traveling is said to broaden your world view, and traveling to another country and culture certainly has broadened mine. The Korean Nurses are fascinated by nursing and advanced practice nursing in the U.S., and would really like to come to New Mexico next fall for the NMNA Convention. If we decide to invite the nurses from the Korean Nurses Association, we will need nurses to take them on tours around northern New Mexico, including tours of APRN independent practices, and perhaps meet with the Board of Nursing. If you are interested in reaching out to the Korean nurses, please contact me at carrie@nmna.org.
Carolyn Roberts, MSN, RN, FNP-BC Executive Director of NMNA
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