Introduction
The Medical Act was first established in South Korea in 1973 to standardize the medical services provided by healthcare providers and related institutions and to protect and promote public health. The medical law of South Korea addresses the issues necessary for all people to have medical benefits (Hong et al., 2018; S. Kim & Choi, 2015). Under the medical law, medical practice by healthcare providers entails certain rights and responsibilities. Although nursing behaviors were previously considered as part of medical treatment in South Korea, this has recently changed as nursing-care-related liabilities are being imposed on nurses rather than doctors because of changes in nurses' self-perceptions of their behaviors (Oh, 2018). Medical law has social law characteristics because it incorporates many acts regarding survival guarantees and public welfare to safeguard the public interest, although medical law has both civil and administrative law characteristics because it includes organizations, procedures, and contents for the actualization of social law (Dronina et al., 2016). In South Korea, default-related medical contracts and compensation associated with illegal acts deal with the civil code as substantive law, including compensation and issues such as the administrative proceedings (mostly insurance fees) of medical institutes, healthcare provider licensing, and sales-related dispositions, which are handled administratively (Heo, 2014). In addition, medical law is connected with criminal law in several important aspects, including medical accidents, medical care insurance law, and the civil and criminal procedural codes (M. Lee, Yoon, & Lee, 2018). Thus, nurses who violate medical law may receive a criminal penalty with a fine, whereas those who fail in their duties may face disqualification or revocation of their license (S. Shin et al., 2020). Nurses who violate their obligations under medical law may receive a criminal penalty as well as administrative disposition. Practicing without a license, distributing false/exaggerated advertising, and practicing outside of approved venues may all result in criminal prosecution (Choi et al., 2019; E. Lee, 2017). Administrative dispositions for nurses may involve the revocation of their license, the suspension of their qualifications, a correction order, a warning, and/or a fine (K. K. Kim et al., 2014). The standards for administrative disposition are described in the administrative rules for violators, with the framework consisting of both common and specific standards. The common standards mainly define general administrative disposition criteria of punitive or reductive disposition regarding an offense and repeat offenses. The specific standards define the duration of license suspension, the revocation of licenses, and warnings regarding offenses and repeat offenses (M. Lee, 2019; W. Lee, Kim, et al., 2018). Depending on the specific standards, a nurse who performs an illegal act such as false charting may be penalized with a fine, warning, or license suspension, with penalty severity depending on the severity of the illegal act and the degree of patient-related damage inflicted.
Although healthcare providers were once the sole decision makers in medical settings, patients are now playing an increasingly important role in medical decision making in South Korea (Oh, 2018). Therefore, legal cases have increased the role of nurses in terms of recognizing their collaborative relationship with physicians for health promotion, with nurses no longer seen as simply doctors' assistants (W. Lee, Kim, et al., 2018). Medical accidents are closely related to nursing care, and related legal violations have increased because nurses are not aware of actions that are prohibited under medical law. In addition, nurses in clinical settings face a higher risk of involvement in legal suits because the scope of nursing tasks has become diversified and specialized, whereas the burden of proof on patients has been eased in medical dispute cases (Jang et al., 2018; Yi, 2018). Therefore, it is necessary to clearly understand the scope of the norms that nurses should follow as caregivers and the administrative standards associated with these norms and to use data to guide and educate nurses on proper decision making. However, there is a lack of research into the scale of administrative measures and the extent of medical law violations by nurses.
This study was performed to identify the current situation of administrative disposition among nurses in South Korea. The specific purposes of this study were the following:
(1) Identify the scale of administrative disposition among nurses in South Korea.
(2) Identify the administrative-disposition violations and their related penalties.
(3) Identify the relationship between the act and standards for administrative disposition.
(4) Develop a plan to reduce the incidence of administrative disposition among nurses.
Methods
Design
A descriptive survey was used in this study to identify the current situation of administrative disposition among nurses in South Korea. This study used raw national data for sampling, tools, and variable selection.
Participants
All of the participants were licensed nurses who were currently practicing nursing in South Korea.
Procedure
The data for this study were collected from January 2014 to December 2018 from 3,553 public health centers after freedom of information requests relating to the administrative disposition of nurses in each city and province (one capital city, six metropolitan cities, eight provinces, and one autonomous city). The collected data consisted of details and standards related to the violation-related administrative dispositions, judgments, acts, and characterizations.
Sample Size
The sample size required for this study was calculated using G*Power software Version 3.1.9.2 (University of Kiel, Kiel, Germany), with an effect size = .3, alpha = .05, and power = 0.90. The calculated sample size for this study was 75. Data were gathered from 3,553 public health centers, and data from the 82 qualified cases with administrative dispositions were included in the analysis.
Study Variables
Details on administrative disposition
Data on administrative dispositions consisted of the nature of the violation, results of the administrative disposition, periods, organizations' requests for a disposition, and judgments on administrative dispositions. Judging administrative dispositions is a governmental power held by administrative agencies, with enforcement measures depending on the specific nature of the violation.
Related law of administrative dispositions
The related law provides rational evidence for administrative dispositions and violations of the law by nurses.
Violations
The violation details for administrative disposition provide the specific reason for a disposition.
Standards of administrative dispositions
The standards of administrative dispositions are the rules governing violations.
Statistical Analysis
The data were analyzed using IBM SPSS Statistics Version 25.0 (IBM Inc., Armonk, NY, USA). Descriptive statistics were used to analyze the general characteristics, details of administrative dispositions, relevant laws, and relevant standards for the dispositions of the participants. Kendall's tau-b correlation analysis for nonparametric data was performed to analyze the relationships among the relevant laws, standards, and administrative dispositions, with p values of less than .05 considered significant.
Ethical Considerations
The data for this study were collected using freedom of information requests to city and provincial health centers. In some cases, a notice of exemption from research proposals was sent to the lead researcher's associated institutional review board (IRB no.: I-1901/3218).
Results
General Characteristics of the Study Participants
The general characteristics of the study subjects are presented in Table 1. Eighty-two cases of administrative disposition of nurses were identified during the study period (January 2014 to December 2018). Nearly all cases (n = 80, 97.6%) involved female nurses. The most common age group placed on administrative disposition was 50s (n = 29, 35.4%), followed by 60s (n = 15, 18.3%), 30s (n = 13, 15.9%), and 20s (n = 3, 3.6%). The most common work region of suspended nurses in administrative districts in South Korea was provinces (n = 51, 62.2%), followed by metropolitan cities (n = 19, 23.2%), the capital city (n = 10, 12.2%), and the autonomous city (n = 2, 2.4%). The most common hospital type affected by nurse suspensions was long-term care hospitals (n = 33, 40.2%), followed by clinics with 30 beds (n = 21, 25.7%), hospitals with fewer than 100 beds (n = 17, 20.7%), and general hospitals with over 100 but below 300 beds (n = 11, 13.4%). There were no cases of suspended nurses in tertiary hospitals. Most nurses affected by administrative dispositions worked for primary and secondary healthcare providers.
Types of Administrative Dispositions and Nature of Violations
The types of administrative dispositions and the nature of violations found in this study are shown in Table 2. The most common type of administrative disposition given was suspension of license (n = 66, 80.5%), followed by a warning (n = 13, 15.9%) and revocation of license (n = 3, 3.7%). Most license suspensions were "more than 1 month but less than 3 months" (n = 31, 47.0%). The most frequent client requesting a disposition was the National Police Agency (n = 39, 47.6%), followed by city mayors/governors (n = 35, 42.7%). The most common court decision was a fine (n = 40, 47.7%), and the average fine was USD$1,512. The next most-common court decision was probation (n = 37, 45.1%). The nature of the violations leading to administrative disposition was as follows: unlicensed medical practice (n = 38, 46.3%), false charting (n = 24, 29.3%), medical practice by a nonmedical practitioner (n = 6, 7.3%), failure to make proper records (n = 4, 4.9%), luring patients by providing valuables (n = 2, 2.4%), license lending (n = 2, 2.4%), immoral medical practice (n = 2, 2.4%), and other (n = 4, 4.9%). "Other" included one nurse who was diagnosed with schizophrenia, one nurse who ordered false medical records to be made, and two nurses who used expired medications.
Fines and License Suspension Periods According to the Number and Standards of Violated Laws
The fines and periods of license suspension are presented in Table 3, organized by the number of laws violated and related standards. No significant relationship was found between fines and periods of license suspension according to the number of violations by nurses. Although the fine amounts did not differ significantly, the duration of license suspension (p = .035) differed significantly by number of specific standards involved, with nurses who had higher numbers of specific standards provided as evidence for their disposition facing longer periods of license suspension.
Discussion
The medical laws in South Korea are designed to regulate the direction of the country's health policy and are thus considered administrative laws (Hong et al., 2018; S. Kim & Choi, 2015; Oh, 2018). South Korea's medical laws regulate nurses (Choi et al., 2019; Oh, 2018). Nurses who fail in their duties may face relevant legal penalties (S. Shin et al., 2020). Healthcare providers who violate their duty under the medical law may face license suspension or revocation based on the severity of their violation. In this descriptive study, the status of administrative dispositions of nurses in South Korea was identified and the specific reasons and standards for administrative dispositions were analyzed.
On the basis of the findings of this study, the number of administrative disposition cases involving nurses numbered approximately 80 cases over a 4-year period. However, accurately estimating the total number of these cases in South Korea is difficult because no data on the number of dispositions by job group are publicly available. However, it is notable that nurses facing administrative dispositions were most likely to be in their 50s, work in nonurban settings (provinces), and work in a long-term care hospital.
It is widely presumed that several administrative measures are used mainly against new nurses because of their lack of experience. However, in this study, most of the administrative measures were used against experienced nurses. In this study, cases of administrative disposition for nurses were most common in the age groups associated with experienced nurses, which raises an interesting question that may be examined in future studies: How do experienced nurses understand the nursing practice in the context of current medical laws? Several nursing studies in South Korea have been conducted on newly graduated and novice nurses with the goal of enhancing the clinical performance of young nurses (Choi et al., 2019; Oh, 2018). However, few studies have addressed the working conditions and abilities of experienced nurses. Therefore, the results of this study suggest that it is necessary to determine whether experienced nurses fully understand the scope of their work and operate within the standards set by medical law.
Distribution inequality exists among medical institutions in South Korea, as most tertiary hospitals in the country are concentrated in metropolitan areas, whereas provincial areas are predominantly the sites of long-term care hospitals and clinics. The main users of long-term care hospitals are older adults. Moreover, the number of long-term care hospitals is expected to continue increasing because of South Korea's rapidly aging society (second only to Japan among the Organisation for Economic Co-operation and Development countries). Long-term care hospitals more often experience shortages of nurses and insufficient patient safety education (Jang et al., 2018). Furthermore, these hospitals maintain vague regulations regarding general nursing practices, and their quality control has been discussed in several studies (J. H. Shin & Hyun, 2015). Thus, on the basis of the results of this study, investigating the status of the scope of delegation of other nonmedical people in nursing practice is necessary to determine whether relevant guidance and supervision are being implemented in accordance with the Medical Act in long-term care hospitals.
The period of license suspension was found to differ based on the severity and extent of the legal violations. In 2018, doctors found guilty of reporting false medical records, ghost surgery, or immoral behavior toward patients such as sexual assault received a license suspension of 1 month (Hong et al., 2018; Jung et al., 2018). Furthermore, doctors who failed to keep medical records, did not sign their records, or formed a medical practice with nonmedical practitioners received a license suspension of more than 3 months (Jung et al., 2018). As doctors and nurses have different duties to perform in clinical settings, it is difficult to compare their punishments in terms of the degree of administrative disposition, but the suspension period for nursing licenses in this study was 1-3 months, and the average fine was roughly USD$1,500, which are comparable with the punishments received by doctors. Although punishment varies based on the severity of the infringement, unlicensed doctors who practiced medicine on people in South Korea received fines of roughly USD$2,000-$2,500. Furthermore, given the degree of punishment in most offenses by nurses for administrative disposition such as false charting and allowing nonmedical practitioners to perform in medical practices, nursing performance is no longer considered medical assistance in the legal context. The dispositions of nurses have changed because their acts are now judged as independent decisions and also because nursing records represent important evidence supporting the validity and results of nursing care, making these records a critical tool for protecting nurses from unintended medical accidents. However, determining whether false charting by nurses leads to dispositions is critical. Therefore, nurses must ensure they do not provide ungrounded nursing care to patients and must write correct, fact-based charts in clinical situations. Hospital organizations must implement systems to ensure nursing practices comply with the provisions of the Medical Act and that written results are accurate and well managed.
The process of administrative disposition for violations of medical laws mostly begins with the filing of a civil complaint, and its procedure is divided into administrative restrictions and criminal penalties. In South Korea, the disposition process is commissioned by the Ministry of Health and Welfare, local governments, or the prosecution, and the steps consist of prior notice, submission of opinions, and execution measures (Jeong, 2013). In this study, the clients were mostly the National Police Agency, mayors, and governors, with suspended nurses receiving a fine or probation proceeding to face criminal or civil suits (Cho & Park, 2019). These results show that nursing practice may be covered by civil or criminal law, except for the facts defined in medical laws. The main reason that medical personnel become involved in criminal or civil lawsuits is criminal negligence that involves serious injury to the patient, with the corresponding administrative disposition also imposed upon the court ruling (Jeong, 2013; Jung et al., 2018). A fine is imposed on the violator for the misconduct, and they must pay a certain amount to the state because of a conviction from the prosecutor. If it is a serious crime, the criminal record remains on that person's permanent record (Cho & Park, 2019). In the past, most professional manslaughter charges involved doctors. However, in recent court cases, nursing practice has been treated as a coequal part of the medical practice, which may be interpreted as giving patients significant responsibility for any damage (K. K. Kim et al., 2014; Jang et al., 2018; M. Lee, Yoon, & Lee, 2018). Therefore, nurses must realize that their nursing behavior will no longer be excepted from medical disputes. Moreover, nursing organizations must establish dedicated departments and personnel to provide legal knowledge and continuously check the legality of nursing behavior to prevent/prepare for medical accidents.
In this study, for nurses, the higher the number of specific standards that applied in the administrative dispositions, the more significant the differences in the duration of license suspension. The specific standards for administrative disposition were defined in this study as the specific criteria for disposal according to the degree of violation, with the more violations and evidential Acts applied, the more standards for the dispositions applied, which may be interpreted as influencing the outcome of the disposal (Heo, 2014; Y. Kim et al., 2019). In South Korea, aggravated punishment may be imposed upon the reissuance of illegalities via the same act, and many violations of medical laws may result in aggravated punishment (Cho & Park, 2019). In cases of excessive misconduct, the administrative disposition criteria related to the medical law shall follow more severe disposal criteria related to the suspension, and the remainder shall be disposed of by adding one half of each disposal criteria. On the other hand, the administrative disposition criteria are not added as punishment if there are two or more violations in the case of false or unpreserved medical records (Jeong, 2013; J. Lee, 2010). Nurses should be careful not to provide patients with nursing care that is not based on medical law because administrative action may vary depending on the violation of medical laws and severity of the action. Although minor breaches of medical law are subject to redress or warning via administrative action, suspension is possible when repeated violations occur. Therefore, nurses should understand clearly the scope of the norms to be followed to avoid unintentional violations.
The importance of patient safety has increased, and the protection of patients' rights is valued around the world. Demand for revision of the Medical Act in South Korea has grown over time, and efforts by nursing organizations and clinical institutions will be required to guarantee the safety and quality of nursing practice for patients and to help nurses avoid administrative dispositions. New nursing knowledge based on medical acts and patient safety will be developed, and further research using surveys and status analyses will be needed to help decrease the number of administrative disposition violations by nurses. In addition, clinical institutions such as hospitals need to organize education and supervision systems based on the Medical Act for nurses who provide care to patients, and nurses must work to gain full legal knowledge so they may avoid administrative dispositions because of unintentional violations of medical laws.
Conclusions and Implications
In this study, administrative dispositions of nurses were most frequently encountered in long-term care hospitals, with the main reasons for these dispositions including unlicensed medical practice and false charting. Moreover, having a higher number of specific standards related to an offense was found to be associated with a significantly longer period of license suspension. The results of this study suggest that nursing behaviors must be based on medical laws and that nurses must maintain correct nursing records. Furthermore, nurses must work to acquire knowledge related not only to medical laws but also to administrative laws, because administrative action may vary depending on the violation of medical law and the severity of the action. This study was the first to use raw, nationwide data to assess the administrative actions taken on nurses who committed illegal medical practices in South Korea. However, as the research data in this study were not obtained using structured questionnaires, the reliability and validity of these data are uncertain. Further research may use in-depth interviews with nurses to determine the reasons behind the illegal actions or decisions taken. On the basis of the findings of this study, future studies should extend the study period or incorporate larger sample populations to assess potential differences related to region, hospital type, career, or level of nurse experience. Because this study was conducted on Korean nurses, it should be easier to interpret the meaning of the findings by comparing each country's medical laws with the disposal of each country's violations and its criteria.
The administrative actions of medical personnel depend on the number and severity of violations. The findings of this study suggest that nurses must understand the details of relevant administrative dispositions to avoid violating medical laws.
Acknowledgment
We thank the people who managed the administrative dispositions of nurses in each city and province.
Author Contributions
Study conception and design: KSH
Data collection: KSY
Data analysis and interpretation: KSH
Drafting of the article: KSH, KSY
Critical revision of the article: KSH, KSY
References