1. Study design

This study was conducted by examining laws and legal orders specifying the roles of registered nurses in the current Korean workforce. Thus, we used a “document analysis” for reviewing or analyzing documents, which is suitable for repeated reviews [16]. Document analysis includes skimming, reading, and interpretation [16]; we used textualism based on their linguistic meaning [17] in the interpretation process. There are numerous methods of interpreting laws, such as textualism, intentionalism, and purposivism [18]. Among these, textualism has the advantage of securing the legitimacy of the law by emphasizing the interpretation's faithfulness to the original meaning [19]. Thus, we chose textualism to focus thoroughly on the meaning of the law itself because the purpose of this study was to compare and analyze the law—in its entirety—as it relates to the scope of nursing practice in Korea.

2. Sample

The legislative system of Korea has been systematized by the Constitution, the law created by the National Assembly for implementing constitutional principles, and administrative legislation created by administrative power for the effective enforcement of laws. Administrative legislation is divided into legal orders that are binding and administrative rules that are non-binding. The objects of this study were the laws and legal orders (enforcement decrees and rules) that were being implemented at the time of January 14, 2018. We excluded laws and legal orders that were enacted or amended before January 14, 2018 but yet to take effect at that time. We searched for the terms “nurse,” “nursing,” and “medical personnel” on the National Law Information Center website (http://www.law.go.kr/main.html), which is operated by the Ministry of Government Legislation.

3. Procedure

The practice scope of registered nurses can be divided according to workplace and practice role. This study mainly analyzed “Where the nurses could work” and “What kind of work they could do.” To begin, we carefully analyzed the extracted contents from the laws and legal orders regarding work qualifications, workplace, and government department in charge of the work. Subsequently, based on the workplace classifications, we analyzed the type of practice among registered nurses using the following developed framework.

The role of nurses in the community is becoming important, as the role of nurses in primary care is being emphasized globally in economic and demographic terms [7]. The World Health Organization (WHO) designated the year 2020 as the “Year of the Nurse” to acknowledge and encourage the fact that nurses play a key role in the realization of universal health coverage (UHC), and the international community is also actively joining in this trend [20]. In 2002, the ICN defined “nursing subjects” as “individuals of all ages regardless of whether they were ill or not,” and “nursing roles” as “advocacy, promotion of a safe environment, research, participation in shaping health policy, and so on, in addition to caring for those who are ill.” [21] This definition aimed to reflect upon and include the broad scope of roles performed by nurses [22]. Therefore, our study focused not only on nurses in medical institutions but also on nurses who are primary health care providers who play an important role in the community. We also aimed to develop a framework that could incorporate all laws related to nursing in Korea in addition to the Medical Service Act, which regulates the nursing practice in medical institutions.

According to Clark [23], nursing activities regarding health promotion and disease prevention outside of hospitals are “community health nursing,” and the scope of services include everything from health promotion to illness care. This classification developed by Clark [23] covers a wide range of areas, from health promotion and disease prevention to medical treatment. Therefore, because the role classification of community nurses proposed by Clark is adaptable to nurses' roles in both hospitals and the community, our research team developed a new analysis framework (Table 1) [23]. This framework was restructured to appropriately cover the contents of the Korean laws. We first matched the nursing activities prescribed in Korean laws to Clark's classification and deleted some roles such as “Role model,” “Case manager,” “Change agent,” “Social marketer,” “Coalition builder,” and “Liaison,” because these were not classified contents or were similar to definitions of other roles. We also integrated “Educator” and “Counselor” under “Client-oriented role” because health education and counseling are closely intertwined [24]. “Educator & counselor” was added to the “Population-oriented role” in order to classify roles by their subjects. In addition, “Caregiver” was subdivided into levels I, II, and III according to degree of involvement in medical treatment. “Advocator” in “Client-oriented role” and “Leader” in “Delivery-oriented role” were developed to fully reflect the contents of the law in Korea. Our research team moved “Advocator” from “Population-oriented role” to “Client-oriented role” and interpreted the type of “Advocator” broadly to reflect the original meaning of “advocate” as encompassing all acts to protect and support the subjects [25, 26]. “Leader” was moved from “Population-oriented role” to “Delivery-oriented role” and integrated with “Coordinator.” We also gave a wide range of new meanings to each type, as supervisor or director, to cover the definitions.

Table 1
Framework to Analyze the Scope of Practice of Registered Nurses

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The classification framework developed in this study incorporates all areas of nurse duties within both medical institutions, as prescribed by Article 3 of the Medical Service Act, and the community. Moreover, the framework is adaptable to Korea's particular circumstances, in which the role of nurses has recently expanded into the community.

To avoid omission of nursing-related content in the laws and legal orders, thereby improving the accuracy of the study, each law from which we extracted content was reviewed four times. Additionally, two researchers categorized and analyzed the content of registered nurses' tasks according to the framework independently. If discrepancies were found between the two researchers, they agreed on a consensus. If no consensus was found, the issue was analyzed by a third researcher. These measures were taken to enhance the credibility of the study.

1. Study selection

As a result of searching the keywords “nursing,” “nurse,” and “medical personnel,” 105, 132, and 107 provisions were extracted, respectively. Of these, 220 were included in the study after excluding 21 duplicates extracted during the keyword search, as well as 103 provisions that were not related to the scope of the registered nurses. The 220 provisions were merged according to their content. It was considered as a single item if the law and the legal orders of the law, or two different laws stipulated the same content. Finally, 119 items related to the scope of registered nurses' practice were extracted from 64 laws (Appendix) and selected for the final analysis (Figure 1). We coded these 119 items by document analysis and the textualism approach.

Figure 1
Flow chart of the search protocol.

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2. General characteristics of registered nurses' practice

First, we analyzed which personnel were authorized to perform the 119 items. Registered nurses can perform all 119 items. However, only 34 of the items can be performed by registered nurses, while the other 85 can also be performed by people in multiple types of occupations such as doctors, pharmacists, paramedics, nurse assistants, nutritionists, and social workers (Table 2).

Table 2
General Characteristics of Registered Nurses' Practice

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Next, we analyzed the qualifications required for registered nurses to perform the 119 items. Fifty-four of 119 items require additional qualifications as well as a registered nurse license. Twenty-eight of the 54 items demand a certain length of relevant experience, and 10 require other certification qualifications, such as being a specialized nurse or firefighting officer, whilst some required both.

As a result of analyzing which ministry manages the 119 items, 72 were found to be managed by the Ministry of Health and Welfare. The remaining were managed by the Ministry of Employment and Labor, the Ministry of Education, the National fire agency, and other organizations.

We then categorized the 119 items by workplace. Thirty-one items were performed in medical institutions such as general hospitals, rehabilitation hospitals, military health and medical services institutions, organ transplant hospitals, medical institutions producing embryos, emergency radiological and medical centers, and infection control rooms in hospitals. Eighty-two were performed in non-medical institutions, and the remaining six items (such as those pertaining to the specialized nurse or mother and child health care specialists) did not mention a specified activity location. Of the 82 non-medical institutions, 26 were government and public organizations, and 22 were long-term care and welfare facilities. The remaining included education and care facilities, amusement facilities, and correctional institutions.

3. Type of practice of registered nurses

Finally, we analyzed the types of practice of registered nurses at each location type (medical or non-medical institution) according to the framework developed in this study. The most common practices of registered nurses at medical institutions were the “Client-oriented role,” followed by the “Delivery-oriented role” (Table 3). The most common type of the former was the combined “Caregiver II/Referring Agent/Educator & Counselor.” The most common type of the latter was the “Coordinator & Leader.” Next, we analyzed 88 items together (the practice of registered nurses at non-medical institutions and unknown locations; Table 4). In these cases, the most common practices were the “Delivery-oriented role,” followed by the “Population-oriented role.” The most common type of the former was the combined “Coordinator & Leader.” The most common type of the latter was “Educator & Counselor.” Many of the roles the registered nurses performed in community were related to professional tasks they performed independently, that is, without the guidance of physicians, including “Caregiver III,” “Educator & Counselor,” and “Community Care Agent.” The other 22 items did not mention what the registered nurses did, despite identifying their place of activity.

Table 3
Type of Practice of Registered Nurses in Medical Institution

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Table 4
Type of Practice of Registered Nurses in Non-Medical Institution and Where the Place Was Not Mentioned

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