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Women’s Leadership and Nursing Profession in South Korea

Abstract The purpose of this article is to introduce women’s leadership in the nursing profession of South Korea. For this purpose, the article will briefly discuss the cultural background of Korean society at the beginning and explain how the values of the traditional society have influenced women’s leadership in the nursing profession in South Korea. Finally, I will discuss my personal experience of leadership development based on Bolman and Deal’s leadership typology, Reframing Organizations: Artistry, Choice and Leadership (2013).


Introduction of the Country: Geography, Socioeconomic, and Women's Index
The Korean peninsula is surrounded by China, the easternmost part of Russia, and Japan. Its total population is approximately 52,000,000 as of July 2016. As represented in the national slogan from a "Land of morning calm" to "Dynamic" and "Creative," South Korea has been recognized as one of the most rapidly transformed countries, which became a developed country within 30 years after the Korean War. As a G-11 country among the Organisation for Economic Co-operation and Development (OECD) countries in 2017, South Korea has the world's highest broadband penetration rate (29.1%) with the world's No. 1 mobile telecom infrastructure.
Facing an aged society, the life expectancy for women was recorded as 85.5 years in 2014, which was 6.5 years longer than that for men. The average health expectancy without a disease was 66 years for women, which was one year more than that for men. In 2016, women comprised 50% of the population and the average age at their first marriage was 30, which showed a continuously increasing trend since 1990 when the average age was 25 years. Divorces from marriages of 20 years or more was 30%. The total fertility rate recorded was 1.24 people. The percentage of single women who thought "they should get married" (39.8%) was lower than that of single men.
The employment-population ratio of women was 49.9%, which showed a steadily increasing trend. However, 40% of women workers were non-regular workers and 47.7% of them were part-time workers (National Statistical Offices & Ministry of Gender Equality and Family, 2017).
In terms of social status of woman in Korea, 73.5% of high school graduates were female. This share was 7.2% higher than that of male high school graduates. In 2016, 77% of teachers were woman in elementary schools, but female principals occupied just 34.5% of the positions in elementary schools. Woman doctors and pharmacists occupied 25% and 64% of the positions, respectively (National Statistical Offices & Ministry of Gender Equality and Family, 2017).
In terms of gender equality, South Korea was ranked 18 th out of 188 countries, but the highest among Asian nations in the 2016 UN rankings (United Nations Development Programme, 2016). However, it has been reported that the Gender Gap Index released by World Economic Forum was 116 th out of 144 countries, which was the worst in terms of discrimination against women at work among the 29 OECD member countries (World Economic Forum, 2016).
In terms of characteristics of the female labor force in 1975, only 2% of the female labor force worked in professional or managerial occupations, while 4% worked in clerical positions. However, by 1998, 12.6% of female employees served in professional or managerial positions, and another 16% were working in clerical occupations. With an increasing number of women entering professional jobs, the government passed the "Equal Employment Act" in 1987 to prevent discriminatory practices against female workers with regard to hiring and promotion opportunities (Korean Overseas Information Service, 2017).

Social Factors Influencing Women's Leadership: Traditional Beliefs and Values of the Korean Culture
The traditional culture of Korea refers to the shared cultural heritage of the Korean Peninsula. Since the mid-twentieth century, the peninsula has been split politically between the North and the South, resulting in a number of cultural differences. Before the Joseon dynasty, the practice of Korean shamanism was deeply rooted in the Korean culture. The original religion of the Korean people was Shamanism, which still survives to this day. Female shamans or muddang are often called upon to enlist the help of various spirits to achieve various means (Connor, 2002).
Buddhism and Confucianism were later introduced to Korea through cultural exchanges with Chinese dynasties. In its place, a strict form of Confucianism, which some see as even more strict as what was adopted by the Chinese, became the official philosophy. Korean Confucianism was epitomized by the "Seonbi" class, scholars who passed up positions of wealth and power in order to lead their lives of study and integrity (Schneidewind, 2016). Confucianism, which is the most different of the religions Korea embraced, emphasized the importance of a patriarchal family where the wife must be devoted and subordinate. The life of women following Confucianism may be summarized as the woman's role of obedience or "the rule of three-fold obedience." The "three folds" were: a woman's father in childhood, her husband in marriage, and her son in old age all reflecting obedience or subordination (Kim, 2013). Women of South Korea were educated to possess virtues of filial piety, loyalty, chastity, and fidelity, whereas the virtue of women revolved around either controlling her body or taking care of her family. Shin Saimdang who lived during the Joseon dynasty (1500-1580) was the most renowned woman, as she is the symbol of "Hyun Mo Yang Cheo," a devoted woman to her family without valuing and/or pursuing her individual life. Contrasting with Mrs. Shin, Heo Nan Soel Hun who was a great poet, painter, and writer, suffered from social discrimination, neglect, and restrictions on her as a woman and ended her life by suicide (Park, 2012).
In traditional Korean society, women's roles were confined to the home. From a young age, a woman was taught the virtues of subordination and endurance to prepare for her future roles as a wife and mother. Women, in general, could not participate in the society as men did, and their roles were limited to household matters. The situation began to change with the opening of the country to the outside world during the late nineteenth century. During this period, modern style schools were introduced mostly by Western Christian missionaries. Some of these schools were founded with the specific goal of educating women (Korean Overseas Information Service, 2017). These educated women began to engage in arts, education, and religious works, enlightening other women. Women also took part in the independence movement against the Japanese occupation, and displayed no less vigor, determination, and courage than the men. With the establishment of the Republic of Korea in 1948, women achieved constitutional rights for equal opportunities to pursue education, work, and public life. With an increasing number of women working in professional fields, there is no doubt that the female labor force contributed significantly to the rapid economic growth that Korea has achieved during the past three decades (Korean Overseas Information Service, 2017).
Korean women today are actively engaged in a wide variety of fields, including education, medicine, engineering, scholarship, the arts, law, literature, and sports. Women are thus making significant contributions to society. With the launch of a new government administration in 1998, the Presidential Commission on Women's Affairs was established to handle issues specifically involving women. The commission was elevated and expanded to become the Ministry of Gender Equality in January 2001. The new ministry set up 20 specific tasks to be achieved in six basic areas. These areas were: (1) to revise and establish laws and rules that involve discrimination in any sectors and to increase the representation of women, (2) to facilitate women's employment and provide support for female workers, (3) to increase educational opportunities for women to be competitive in the labor market, (4) to provide social welfare policies for women, (5) to promote women's involvement in various social activities including volunteer work and women's organization activities, and (6) to strengthen the cooperation of Korean women's organizations with international women's organizations (Korean Overseas Information Service, 2017).

History of Nursing in Korea
The official nursing education program in Korea was started by a missionary nurse, Margaret Edmunds, in 1903, at a nursing training school in a women's hospital, Bogu Yeokwan (Y. Lee, 1991). Missionaries ran the early nursing training center in Korea. It did not receive much attention from the government or from the society as it was in the midst of World War II. Because most directors of the training centers were physicians, nursing education was relatively low quality (Y. Lee, 1991). Institutions run by missionaries from Europe and the United States focused on hospitalized patients using a patientcentered approach. However, national or private training centers focused on nurses' roles as physicians' assistants, and this focus came from Japanese influence (Y. Lee, 1991).
In the mid-1940s, as the country became independent from the Japanese colony, all the school systems transferred their superintendence to the Ministry of Education (Y. Lee, 1991). In 1947, the nursing training center was promoted to a high school for nursing. During this time, nursing education consisted of three-year courses, which was equivalent to a high school education, and major qualification for admission to the school was junior high school diploma. The length of a nurse's education was unified to three years across the nation (Y. Lee, 1991). In 1949, the nursing discipline took a higher step in its advancement with its registration as a regular member in the International Council of Nurses (ICN). However, the Korean War, which broke out in 1950, interrupted this progress. After the Korean War, which ended in 1953, the Korean government focused its efforts on developing an industrialized and modernized country. The high schools for nursing were considered as technical schools, influencing nursing high schools to change their names into Technical Nursing High Schools. However, in the late-1950s, nursing leaders presented a proposal to the government to either promote or abolish the technical level of nursing education. Upgrading nursing education to the college level naturally followed. The first Masters programs in nursing started in 1963 and the first doctoral program was approved by Yonsei University in 1978. In 2015, there were a total of 203 nursing schools with Bachelor of Science in Nursing (BSN) programs.

Nursing's Image and Views on Nursing in Korea
Nurses' image has been improving mainly due to nursing's professional status with a higher employment rate and salary rate compared to other jobs for woman. The job title of nurses started with "Ganho-Bu," with "Bu" meaning the housewife. In 1945 after Korean War, it was changed to "Ganho-Won," with "Won" connoting "worker." Finally, in 1987, it was changed to "Ganho-Sa," with "Sa" connoting "teacher." In the highly honorific Korean language, words referring to professionals end with "Sa"; for example, "Ui-Sa" for doctors, "Pyonho-Sa" for lawyers, and "Yak-Sa" for pharmacists. Changes in the title of nurses gave nurses an improved self-image, and improved nurses' public image. The improved professional status of nursing in South Korea resulted in increasing the number of male nurses who sought nursing as their life-long career. In the 1970s, only 3% of nurses in South Korea were men. However, currently, it is estimated that 11% of nurses in South Korea are men (Korean Nurses Association, 2015). Facing the 4 th industrial revolutionary age, the nursing profession, which focuses on human caring, is expected to be a necessary and required profession in the future.
In a recent study conducted by Yom et al. (2015), views on nurses by 1,507 people in 42 hospitals, were more favorable than those about physicians in terms of kindness, promptness, being responsible, being sensitive listener, and providing skilled healthcare. However, people perceived nurses as "followers" rather than leaders. Furthermore, people saw nurses as passive, obedient, and limited healthcare providers in decision making for patients. Nurses' roles as educators, advocators, and coordinators are limitedly recognized. This could be interpreted within the contexts of healthcare environments in South Korea. Nurses in South Korea do not have the prescription privilege, which could result in nurses' inactiveness in decision making or leading the health care. With advances in nurses' professional status, the Advanced Practice Nurse (APN) system has been established in South Korea since 2003. However, there still exist no legal regulations on the scope of practice or health insurance coverages for APN in South Korea (Seol et al., 2017). In addition, the bureaucratic atmosphere in the Korean health care systems that place physicians in central administrative positions has weakened the leadership of nurses in the current health care system. B. J. Lee (2013) explored the factors influencing nurse-physician conflicts in South Korea using a qualitative method, and reported that both nurses and physicians identified conflict sources as task overlaps, lack of competence, negative attitudes toward the other party, ineffective communication, and a lack of interpersonal skills of physicians.
The nursing profession in South Korea is often viewed as a hard and tough profession, stigmatized as one of the avoided jobs, called 3-Ds: "dangerous," "difficult," and "dirty." According to a report by the Korean Hospital Nurses Association in 2016 (Korean Hospital Nurses Association, 2016), nurses in South Korea had a turnover rate of 12.4% and the turnover rate went up to 33.9% among nurses with less than a year of experience. By contrast, the average turnover rate for workers in general in South Korea was 4.7% in 2014, according to the Ministry of Employment and Labor (2014).
The medical industry of South Korea is highly stratified while having big general and university hospitals at the top of the ladder. They are the places where patients want to be admitted, and they are prestigious workplaces for both physicians and nurses. According to the Korean Nurses Association (Korean Hospital Nurses Association, 2016), a South Korean nurse takes care of an average of 12-13 patients on a shift, which is much higher than the average of 10 patients in the United States, and the average of 8.8 patients in major European countries (Ministry of Health and Welfare, 2014).

Nursing Influences on Patient Outcomes
Healthcare environments have been dramatically changing in South Korea. With the Institute of Medicine's (IOM) evaluation criterion for healthcare outcomes, efficient and effective health has been emphasized in clinical settings. In hospitals, there is an increasing emphasis on managing programs based on a business model that stresses fiscal and organizational efficiencies. This leads to shorter hospital stays and waiting times for procedures, integration of services to reduce duplication, and computerized information management systems. The result is a more complex care environment with an increase in the acuity and complexity of patients remaining in hospital, which may increase risks to provision of quality care.
Quality Improvement (QI) and Evidence-Based Practice (EBP) have been big issues in Korean nursing. The accreditation of Joint Commission International (JCI) and the Association for the Accreditation of Human Research Protection Programs (AAHRPP) for clinical trials has been rapidly employed in the research and educational mega hospitals in South Korea. Nurses working in these hospitals are highly responsible and are major human resources involved in improving quality indices for the hospitals. The National Customer Satisfaction Index (NCSI), which is a national survey for healthcare customers' satisfaction on hospitals/institutions, has become an important indicator in advertising hospitals'/institutions' quality of care. Nurse managers and staff nurses play major role in providing high quality of care that could satisfy their consumers. Patients' outcome variables can be grouped into four categories considering the relationships between leadership and (1) patient satisfaction, (2) patient mortality, (3) patient safety outcomes including adverse events and complications (for example, medication errors), and (4) patient healthcare utilization (Doran & Pringle, 2011). Thus, nursing impacts these outcomes greatly through their efforts in the QI, the EBP, and innovative healthcare service development.
It has been proposed that even though nurse leaders may directly impact outcomes at multiple levels (individual nurses, groups or units, and organizations), their influences on patient outcomes are indirect and/or take time to have visible impacts (Lord & Dinh, 2012). The leaders could facilitate changes in nurses' work contexts and influence nursing staff's attitudes and behavioral performances. They could improve working conditions that promote optimal patient care, create open communication channels with nursing staff that support high quality of care, or promote positive relationships with staff that encourage their motivation and engagement in work (Cummings et al., 2010). Wong, Cummings, and Ducharme (2013) published a systematic review of the research literature to identify the state of knowledge on the relationships between nursing leadership and patient outcomes. They found that leadership styles of nurses in management roles could influence patients' satisfaction, mortality, adverse events, and complications. In practice, we know that effective nurse leaders strive to ensure adequate staffing and other resources to achieve high quality of care. At higher levels of organization, senior nurse executives influence how nursing is practiced and valued through their roles in policy making (Huston, 2008;Wong, Laschinger, Cummings, Vincent, & O'Connor, 2010). Thus, effective nursing leaders are critical in South Korea to advance nursing's agenda to provide cost effective care, improve patient outcomes, and attract and retain nursing staff (Fine, Golden, Hannam, & Morra, 2009;Lowe, 2005).

My Own Leadership Journey
As a child raised in a family of educators, I naturally dreamed of becoming a nurse teacher as my life-long profession. I had worked in an Intensive Care Unit (ICU) where I was impressed by and favored to provide, highly touched and skilled care for high-risk patients. Working in highly complex and technically advancing environments had challenged me to study more in an advanced nursing program. As a staff nurse working at ICU, I began my master's degree in 1988 because I was struggling with my lack of confidence in knowledge and skills to be a competent nurse. While working on my masters' thesis, I had to choose my final career path from the dual roles of a clinical nurse or an educator. Since I had found my strengths in education, I quit the staff nurse role and started to work as a teaching assistant at the college of nursing for two years after completion of my master's degree.
By the time I started my graduate study in 1988, the annual conference of the International Council of Nurses (ICN) was held in Seoul, South Korea. I had a chance to serve global nurse leaders as a graduate student volunteer. Having the opportunity of serving, communicating, and networking with global nurse leaders about whom I had only read in textbooks was not only an unforgettable but a deeply motivating experience for me to set my goal beyond a local level. After that, I dreamed and planned for my Ph.D. study in the United States. In the early summer of 1991, I went to Bloomington, Indiana, with my husband who was about to begin his doctoral study there. Three years later, I finally started my own Ph.D. study at University of Illinois at Chicago (UIC), after supporting my husband to complete his course works for his Ph.D. at Indiana University. I moved to Chicago with my husband and son, Luke, who was nearly three years old. During my first year in the Ph.D. program, my daughter was born. As a foreign student, I had language barriers and struggled with balancing working as a research assistant and being a wife and mother for two children. Thanks to strong support from family, friends, and faculty mentors, I successfully completed my Ph.D. and returned to South Korea at the end of 1998.
During my doctoral research on asthma symptom experience, I was mentored by Dr. Janet Larson, who is now at the University of Michigan. Working with her was a privileged experience and a precious time for me. I learned a lot about how to structure, organize, and manage my priorities focusing on research. As I was the first foreign student for her, she always took care of me not only as my academic advisor, but also as a mentor in life. I had also worked for Dr. Carol Ferrans as a research assistant, mainly in data clearance, statistical analysis, and instrumentation. My research capability and performance significantly improved through these experiences. I found structural resource, human resource, and symbolic leaderships from both of these mentors (Bolman and Deal). In addition, brown bag seminars with newly employed post doctorate researchers at UIC heavily influenced me to enrich research ideas and plan ahead my research goals and trajectory. Above all, I learned strong leadership from Dr. Mi Ja Kim who served as the vice chancellor of the university following her service as a dean of the College of Nursing at UIC. As a minority Korean woman, she was already known as a passionate and inspiring role model through her leadership in many respects. Dr. Kim emphasized the vision of the nursing profession in the engagement of vulnerable populations, and nursing leadership in the advancement of healthcare quality. She always helped nurse scholars with minority backgrounds to empower their cultural literacy in the new environment.
Returning to South Korea, I landed a job at my alma mater, Yonsei University, which has long been the home for nurse leaders in the country. One good example is Dr. Mo Im Kim, a former president of ICN, who is a living legend in Korean nursing. As the first and foremost woman who worked for the South Korean government as a minister of health and welfare, she has consistently inspired nurse scholars to be vibrant leaders. She demonstrates structural, political, and symbolic leaderships. Dr. Kim was a professor when I was an undergraduate and graduate student. She was a smart teacher who always stimulated us with near-perfect professional attitudes. She established the first community nurse practitioner program and started the community care act in South Korea. As a director of the Mo Im Kim Nursing Research Institution, I am currently working on a project to establish visions, long term goals, and strategic plans for the "future of the Korean nursing profession," which could disseminate and be a guide to advance the nursing profession in South Korea.
In addition, I played major roles as the first Chief Review Board for Nursing Research and Development at the Korean National Research Foundation in 2012. Since 2014, I have been a member of Program Management in the Ministry of Health and Welfare and served as an executive board member for the Korean Academy of Nursing, and the Seoul Nurses Association. All of these positions are critically important to advance and improve the nursing profession. The roles I have require competences and talents in many areas that I am not naturally endowed, but I try to remember what my mentors have taught me whenever I confront seemingly impossible tasks. In the hope of stretching my capacity beyond the nursing specialty, I took a mini-MBA course for a semester and learned various leadership qualities that are effective for the management of organizations. This learning opportunity helped me to analyze and reflect on myself as a leader, and to recognize my weaknesses, especially in political leadership.
In my roles, I faced many challenges in performing the responsibilities and burdens placed on my shoulders: (1) being a competent educator and researcher, and a responsible nurse scholar, volunteering for services at professional societies; (2) being a competent mother, as "Hyun Mo Yang Cheo" like Shin Saimdang (an ideal image of married woman in Korean culture); and (3) being a wise wife and daughter-in-law for the first son in their family who had responsibilities to maintain in-law's dignity and traditions. Overcoming and balancing these responsibilities was accomplished by trial and error. Emotional and financial support from both parents and husband were critical. During the process, strategies for self-control were the most important things to overcome barriers in my leadership development: (1) set a clear vision or individual life goal; (2) prioritization of the work based on the importance and urgency; (3) development of networks intra and inter professions; (4) learning leadership by serving as role models; and (5) development of leisure/hobbies with a positive mind-set to manage stress. Bolman and Deal (2013) have identified four patterns inherent in leadership: structural, human resource, political, and symbolic leadership. In the model, they suggested to integrate multiple frames into a comprehensive approach to leadership.

Best Theoretical Frame for Women's Leadership in South Korea
Structural leadership includes rethinking the relationships among structures, strategies, and environments, focusing on implementation and experimentation. This is effective particularly when a new system or organization is created. My role as a director of a research center would require structural leadership. Since the research institution has transformed to lead research and development not only at the institutional level but at the national and global level, I had started to set up the vision, goals, and strategic plans based on a SWOT (Strength, Weakness, Opportunity, & Threat) analysis. Through my leadership experience I have learned that it is important to establish a clear vision and feasible strategies based on consideration of cultural contexts (e.g., situational analyses not only for nursing education, research, and practice, but also for healthcare policy and industrial development strategies in South Korea). To set up these plans, I have structured the planning and steering committee. In addition, the newly established vision, goals, and strategic plans were shared by the school to confirm the effectiveness and efficiency, having synergic impacts for both organizations.
Human resource leadership includes communication of a strong belief in people, and empowerment for others. This type of leadership views the leader as a facilitator who is visible and accessible, and a catalyst who uses emotional intelligence and social skill to motivate and empower. This leadership example is useful for the newly graduated nurses or students who have begun nursing as their life-long profession. They might have high levels of anxiety that come from the strict rules and regulations to perform seamless care without errors, eventually provoking high emotional tension. Human resource leadership will help improve adaptation and successful adjustment for the nursing profession and healthcare settings with thoughtful, tailored, and prompt emotional support. I have guided newly admitted graduate students with human resource leadership to help them successfully transform into a respectable and competent researcher.
Political leaders, characterized by Bolman and Deal (2013), clarify what they want and what they can get, often more interested in the distribution of power and thoughts of major players such as Congress and the public. They first persuade, then negotiate, and coerce only if necessary. In South Korea, the nursing profession has long struggled to set up the "Nursing Care Act" separated from the Medical Service Act. Under the Medical Service Act, the nursing profession is defined as a dependent discipline to medicine. Again, there are no prescription rights for nurses in South Korea.
The Korean Nurses Association was founded in 1923 and has seventeen regional chapters and ten affiliated organizations, including the KABONE (Korean Accreditation Board of Nursing Education). The Korean Nurses Association is committed to upholding Korean nurses' social position and building nursing professionals' competencies. It developed its first code of ethics in 1972, which has subsequently been revised to the level of global standards. Regarding the expansion of nursing practice, Dr. Mo Im Kim had a vision of a global-oriented humanistic approach to nursing practice. She placed a particular emphasis on the necessity of public health nursing and has created a number of training programs for public health nurses. Ultimately, her efforts contributed to the enactment of legislation on special measures for public health and medical services in agricultural and fishing villages, and to the 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. Yet, despite all that has been accomplished, the weakest leadership in nursing is the political leadership.
Lastly, symbolic leadership has been suggested. This type of leader leads through examples and use symbols to capture attention. They also frame experience and communicate a vision by telling stories, a persuasive and hopeful image of the future. I think that this type of leadership is not frequently used by leaders in South Korea, and needs to be further developed. As a fellow of American Academy of Nursing (FAAN), I have regularly received emails from the President that urged nurses to engage in advocacy roles in improving health equity for minorities and vulnerable populations. Her messages are clear and persuasive enough to make me rethink nursing profession's social responsibilities.

Suggestions for Future Women Leaders
With rapid socioeconomic and political changes in South Korea, the nursing profession has faced various challenges to advance healthcare and to meet consumers' needs. New leadership is essential in Korean nursing to transform traditional, hierarchical, centralized, and charismatic leadership into leadership based on more horizontal relationships through decentralization and middle-up-down strategies.
As Bolman and Deal (2013) suggest, leaders have not been fixed into one specific type of leadership; rather it has been recommended to use complementary styles and strategies. Leadership training is necessary, as many leaders may not be born with natural leadership skills. Development of a career ladder for leadership is necessary for those who prepare to take a leadership position. Training and education for young nurse leaders are critical for the future of nursing. In addition, nurse leaders with social, emotional, as well as informational intelligence are definitely needed as our society is equipped with more advanced information and technology.
Looking back on my career, the most significant aspect I was fortunate enough to have in my journey were people, whom I met and learned from. In the personal realm of my life, they include my family members and friends. More importantly, in the area of my profession, I had great mentors and teachers. There is a saying, you are what you read. I would say, in a similar vein, you are who you have sought to learn, emulate, and overcome. Find good people whom you want to emulate and keep watching, reading, following, and persevering. Never let them leave from your life.

Declaration of Conflicting Interests
The author declared no potential conflicts of interest concerning the research, authorship, or publication of this article.