On July 13, the Korean Health and Medical Workers' Union (KHMU) began their first general strike in 19 years. Over 45,000 workers from about 60 different professions working in hospitals, including nurses and nursing assistants, held assemblies across the country. The workers aim to reform the current health care system by demanding the government expand the nursing workforce. The government has labeled it a "political strike" that is causing division in the health care system and is demanding union members to stay at work.
A heavy workload, an arrow toward patients
The background of nurses' desire to enact the nursing law is overwork. They insist that laws be enacted to limit the number of patients under the charge of each nurse and prevent nurses from working in other professions. According to the data presented by the Korean Nurses Association (KNA) in 2022, there is an average of 16.3 patients per nurse currently working at Korea polyclinics, while at general hospitals the number is close to 43.6 patients. This is about seven times higher than the OECD average of six to eight.1) It shows that Korean nurses have no choice but to spend less time on each patient than nurses in other countries. Regarding this situation, Gong Ji-hyun, head of Hanyang University Medical Center, who has been working as a nurse for 25 years, said, "I didn't know how long I could keep working for because there were so many patients to take care of and I didn't even have time to go to the bathroom or eat."2) This shows a situation in which nurses continue to take care of patients without being guaranteed rest and meal time because the amount of patients is not fixed. This further suggests that high work intensity can increase nurse turnover.
Along with high patient rates, the role of Physician Assistant (PA), which partially replaces doctors' work, also affects nurses' work overload. Since nurses' work is only applicable to patient care and medical assistance under the guidance of doctors, procedures such as blood specimens, X-ray photography, and drug prescription that occur naturally in hospitals are illegal for nurses to do. On May 24, a total of 12,189 cases were reported to the illegal medical reporting center by the KNA. This shows the reality that nurses have to do tasks in many hospitals that are not their job. Hospitals and workers know this situation is wrong, but it is not easy to refuse work because PA regulations are not clearly stipulated in the law. This overload for nurses not only prevents them from focusing on their patients, but also makes it difficult to provide high-quality medical services.
What are the options to help patients?
If the nursing law is passed, KNA argues that high-quality medical services can be provided to patients because the problem of overwork can be solved. According to a job satisfaction survey released by the KNA in 2022, as a result of conducting nursing services by deriving the appropriate number of patients with hospitals applied in the study, job satisfaction due to reduced labor intensity was recorded at 4.4 out of 5. This also led to patient satisfaction and medical service quality improvement scores reaching 4.4 points, 1.3 points higher than before. This had the effect of increasing their satisfaction because nurses could invest more time in them. The nursing law can also serve as a solution to the elderly-care problem facing Korea as it becomes a super-aged society. According to statistics released by the National Statistical Office in 2022, the number of elderly people aged 65 or older was 9 million, exceeding 17.5 percent of the total population. In addition, it is predicted that the proportion of senior citizens will reach 20.6 percent in 2025. In response to this situation, Kim Hye-suk, a nurse who has been working as the head of an emergency room for 30 years, said, "In the emergency room, there are many situations where people lack cooperation due to the increase in elderly patients and lack of understanding of the emergency system. Since there are many situations where guardians feel burdened by caring for elderly patients, we are busy providing not only first aid but also care."3) It shows that the burden on nurses may increase as patients' average age increases. This suggests that elderly patients need more attentive nursing than patients of other age groups, but nurses may not be able to take good care of patients due to a lack of manpower. Therefore, if the nursing law is enacted, the work of nurses will be clearly defined and it will increase patient satisfaction.
However, there are concerns that the move to enact the nursing law could cause division in the medical community. The key reason for the conflict between doctors and nurses over the nursing law is the possibility of nurses opening their own clinics. Article 1 of the nursing Law stipulates that all citizens can receive high-quality nursing services from medical institutions and local communities. Regarding this clause, the Korean Medical Association (KMA) criticized it as providing nurses with an opportunity to open a hospital alone, based on the phrase "community benefits." If nurses open alone, doctors argue that their organizational quota and their income will be reduced. Currently, there is a legal limit to nurses opening up independently, but if the proposed law succeeds in separating it from the existing medical law system, they will be able to open clinics independently through the revision. It is also pointed out that the increase in labor costs is inevitable, which could disrupt hospital operation. This is based on the fact that if nurses' work is clearly identified through the law, additional people from other occupational groups would need to be hired to do the work previously performed by nurses. This could soon lead to a rise in labor costs, causing difficulties in raising employee salaries. Hospitals are already burdened by the cost of spending on fixed medical items and labor costs, so hiring more people makes it difficult to raise the salaries of nurses. The KMA and KNA are also at odds over the increase in demand for elderly care due to the aging population. The KMA argues that the KNA's position that the nursing Law will improve care for the elderly is not convincing enough and cannot be used as a basis for enactment. Lee Pil-su, chairman of the KMA, criticized it by saying, "The enactment of the nursing Law only means that the role of nurses will continue to be expanded, and elderly care can produce the best results when various health and medical fields collaborate organically."4) This suggests that it will not have a direct impact on elderly care, and that success can be achieved through organic collaboration between various medical fields. There is no disagreement between the two sides that they should do their best to treat patients, but opinions are divided on whether the solution is to enact the nursing law.
A suggestion for the next best option
Conflicts in the medical community about the nursing law centered on the changes it will bring and the concerns it raises are ongoing. The KMA and the KNA disagreed on the content of the nursing law. For the KMA, they argued that clarifying the scope of duties for only nurses, rather than the entire medical profession, would lead to confusion in the field. Refuting these statements, the KNA said that clarifying the scope of duties for nurses is a contribution to the entire system. With the continuing disagreement between the medical professions, the nursing law also gained political attention. In the last 20th presidential election, candidates from both major parties sought votes by promising to improve the treatment of nurses. However, as the nursing law debate intensified, doctors strongly expressed their opposition, and the ruling party took a passive stance in enacting the law. On February 9, the opposition parties unilaterally brought the nursing law to the Assembly plenary session, which was different from the usual process of going through the Legislation and Judiciary Committee, sparking a political conflict. On April 27, the nursing law passed the plenary session of the Assembly, intensifying conflicts in both the political field and medical community. Under these circumstances, President Yoon Seok-yeol vetoed the nursing law. About this situation, Pamela Cipriano, president of the International Council of Nurses, said, "In other countries that have enacted the nursing laws before South Korea, there has been no conflict between professions. While public debate is necessary in the legislative process, the health care community must work as a team for patient safety."5) This indicates that conflicts between medical professions in Korea have prevented medical staff from improving the health care environment and have caused confusion for patients. As the nursing law has failed to be enacted, there is a need for an alternative to solve the problems of the current medical system.
The problems facing the health care system have been revealed and discussions have begun to address them. According to the results of the KHMU's survey released in 2023, 74.2 percent of the total nursing workforce works three rotations. Among them, 91.8 percent reported experiencing extreme fatigue and stress after their rotations. These statistics show that the current working arrangements are contributing to the poor treatment of nurses. The government has proposed the Nurses' Flexible Work Scheme Pilot Project as a solution. In response to three eight-hour rotations, the flexible work system allows them to autonomously choose when they work, including night rotations and fixed rotations during the day or evening. Time options are offered based on each nurse's workload and the difficulty of their assignments. Flexible working hours can contribute to the stabilization of nurses' work, but since it is a pilot project, there is no obligation for hospitals to implement it. To overcome this limitation, it seems necessary to evaluate the effectiveness of the flexible work system and enact it into law. Policy direction also needs to meet the care of the elderly, which is another element to the nursing law discussion. Kim Ki-joo, the vice chairman of the Nursing Home Association, said, "The medical nursing care system should be coordinated with medical care and welfare, but due to the dualized organization of the Ministry of Health and Welfare, it is difficult to achieve integrated coordination of elderly health and welfare."6) This indicates that the current fragmentation of elderly care services is preventing the elderly from receiving the medical support they need. In response to these comments, the Ministry of Health and Welfare proposed the medical care and care integration support law which aims to systematically manage the elderly population by integrating medical, nursing, and care services. In addition, the law contains future-oriented health care services to prepare for an aging society, such as expanding the number of elderly support personnel like doctors and caregivers. These proposals are aimed at changing the current system, which is what the nursing law was designed to accomplish.
A better step for the society
The nursing law was proposed to improve the treatment of nurses and prepare for the demand for elderly care in a super-aged society. Despite the goals of the law, conflicts among each of the political and medical communities led to the failure of its enactment. Although the nursing law has not been implemented, the issues that were publicized during the debate remain to be solved. In order to deal with these issues, it seems necessary for the medical profession to work together to enact measures to improve the health care of the people.
1) Cheon Ho-seong, Im Jae-hui, "The Number of Patients per Nurse Is Three Times That of Advanced countries...16 People → Reduce to 5 People", The Hankyoreh, April 25, 2023
2) Park Jeong-yeon, "Why Did Nurses and Therapists Go on a Massive General Strike for the First Time in 19 Years?", Pressian, July 13, 2023
3) Mun Seon-hui, "Community "Nursing Care" Is Not an Option, but a Necessity... "Enact a Nursing Law."",e-medical information, April 20, 2023
4) Yun Jin-ho, Choi Won-guk, "What's the Nursing Law... A Fierce Battle Between Doctors and Nurses", Chosun Ilbo, April 13, 2023
5) Baek Yeong-mi, "Head of the International Council of Nurses "Conflict Over Nursing Law Is Unprecedented Overseas"", NEWSIS, April 7, 2022
6) An Gyeong-jin, "Finding an Alternative to the Nursing Law... Experts, "This Will Only Hurt the Public"", The Seoul Economic Daily, July 7, 2023
Lee Gayun / Editor-in-Chief
Jo Yoo Suyeon / Reporter