An immersion program for clinical nurse leader students: Comparing health care systems in South Korea and the United States

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Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu

An immersion program for clinical nurse leader students: Comparing health care systems in South Korea and the United States Danijela Pavlica, , Harold H. Burnsa, Alex Wonga, Joshua Lehmera, Hee Chong Baekb ⁎

a b

School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA School of Nursing, Chung Ang University, Seoul, Republic of Korea

ARTICLE INFO

ABSTRACT

Keywords: Study-abroad Immersion Korea Clinical nurse leader MSN

We examine the import of a Comparative Health Care Immersion Program in South Korea to prepare entry-level Master of Science in Nursing (MSN) students studying to become clinical nurse leaders (CNLs) who can dynamically engage the complex issues facing health systems in the United States (U.S.). Following passage of the Affordable Care Act, clinical nurse leaders are being expected to have insight into systems level issues and ameliorate them when they are related to poor patient outcomes. Examination of South Korea's health care system provides U.S. students an opportunity to see the design and action of a highly functional system and thus benchmark the U.S health care system. South Korea provides a useful comparator given their rapid development of a universal, single-payer health care system that uses advanced centralized computing and provides outcomes on par and surpassing the U.S. We explore implementation of a CNL competency-based curriculum, including financing, informatics, and health care efficiencies within the context of short-term study abroad.

Introduction The Comparative Health Care Immersion Program in South Korea was created to expose Master of Science in Nursing (MSN) students who are studying to become clinical nurse leaders (CNLs) to the South Korean health care system. This elective program, which focuses on South Korea's many advances in financing, informatics, and efficiency, has been offered in January between regular semesters in 2014, 2015, 2017, and 2019, with two missed years due to logistical reasons outside of faculty control. The program, inspired by the first author's immersion experience in the South Korean health care system in 2013, has gradually been extended from 10 to 16 days and has increased the number of students from 14 to 41. Students elect to participate, and preference is given to those closer to degree completion. Although the immersion program is optional, it incorporates courses required by the curriculum. Thus, students in the program do not have to complete those courses in the United States (U.S.). This article is based on the 2017 iteration of the immersion program during which 41 students participated in the 16-day program. The 2017 program incorporated two required courses: Healthcare Policy and Ethics (3 units) and CNL Role Course: Comparative Healthcare Immersion (1 unit). The immersion program was conceived by and has been directed by the first author since its inception. It comprises three distinct but interrelated components: experiential learning, didactic learning, and ⁎

socio-historical activities. The first author has partnered with Hee Chong Baek, RN, MPH, PhD, other nursing faculty, and administrators at Chung-Ang University (CAU), the host university, to organize program logistics. The experiential portion includes visits to the country's National Health Insurance Service (NHIS) and Health Insurance Review and Assessment (HIRA) headquarters in Wonju, and hospitals and clinics in Seoul; CNL simulations; and nursing student “buddies,” that is, BSN students from CAU. The didactic portion features lectures by U.S. and South Korean nursing faculty and South Korean health care experts as well as in-depth briefings before and debriefings after lectures, institutional engagements, and simulations. The program's third component entails ceremonial and socio-historical activities, such as museums and palaces, and traditional meals. A detailed description of the program is presented in Table 1. Attendance at lectures and institutional visits is mandatory and essential to evaluate what students learn; the ceremonial and socio-historical activities are encouraged but optional. Learning is evaluated in daily debriefings with the whole group; debriefings with small groups (13 students, one faculty member, and a teaching assistant) occurred every other day. At the final lecture on the program's last day, faculty address student questions on concepts that remain unclear. This final lecture further elucidates the pros and cons of the South Korean and U.S. health care systems, while contextualizing the observations and experiences the students have shared. On completion of the immersion program, students' learning is assessed

Corresponding author. E-mail address: [email protected] (D. Pavlic).

https://doi.org/10.1016/j.profnurs.2019.07.006 Received 28 October 2018; Received in revised form 21 July 2019; Accepted 26 July 2019 8755-7223/ Published by Elsevier Inc.

Please cite this article as: Danijela Pavlic, et al., Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2019.07.006

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CAU Hospital (HC Baek, personal communication, September 2019).

Kyung Hee University Medical Center

●

● ● ● ●

2704 bed hospital 14,000+ patients seen daily 63,791 operations yearly 27 specialized centers 44 clinical departments 8 specialty ICUs Asan Medical Information System ○ OCS: order communication system ○ EMR: electronic medical record system ○ PACS: picture archiving communication system ○ DW: data warehouse ○ ERP: enterprise resource planning ○ DR: disaster recovery ○ U-health: ubiquitous health ○ e-MED: electronic medical contents and electronic learning 400 bed hospital Specializing in Korean medicine Korean herbal medicine compounding pharmacy 836 bed hospital ○ Outpatient: 714,000/year ○ Inpatient: 239,201/year Awards ○ Cancer evaluation ■ Best in all categories - awarded by HIRA ○ Emergency Medical Center: ■ Best in nation award - 8 years running awarded by Ministry of Health and Welfare ○ Medical quality and patient safety area:

The Health Insurance Review & Assessment Service (HIRA) reviews and assesses health care costs and health care service quality, as well as supporting the national health insurance policy in determining medical fee schedules and drug prices.

HIRA

● ● ● ● ● ● ●

National Health Insurance Service of Korea (NHIS), a single insurer, is in charge of operating and managing national health insurance.

NHIS

Asan Medical Center (Asan Medical Center, 2017)

Organizational functions

Organizations

Table 1 The comparative health care systems immersion program in South Korea.

Organizational and Systems Leadership (Essential 2.1–2.8)

Quality Improvement & Safety (Essential 3.1–3.11)

Master's Level Nursing Practice (Essential 9.17)

Organizational and Systems Leadership (Essential 2.1–2.8)

Quality Improvement & Safety (Essential 3.1–3.11)

Clinical Prevention and Population Health for Improving Health (Essential 8.1–8.6) Informatics & Health Care Technology (Essential 5.1–5.7)

Organizational and Systems Leadership (Essential 2.1–2.8)

Quality Improvement & Safety (Essential 3.1–3.11)

Clinical Prevention and Population Health for Improving Health (Essential 8.1–8.6) Informatics & Health Care Technology (Essential 5.1–5.7)

Organizational and Systems Leadership (Essential 2.1–2.8)

Informatics & Health Care Technology (Essential 5.1–5.7)

CNL competencies

“Exploitation of the power of IT for learning through development of evidence, capacity for data collection and analysis, simulation and testing, distance learning, collaborative connectivity, and management of the increase in knowledge.” “Developing the competencies to access, discriminate, analyse, and use knowledge.” “Teaching students how to think creatively to master large flows of information in the search for solutions” (Frenk et al., 2010, p. 1951).

“Exploitation of the power of IT for learning through development of evidence, capacity for data collection and analysis, simulation and testing, distance learning, collaborative connectivity, and management of the increase in knowledge.” “Developing the competencies to access, discriminate, analyse, and use knowledge.” “Teaching students how to think creatively to master large flows of information in the search for solutions” (Frenk et al., 2010, p. 1951).

“Alongside specific technical skills, interprofessional education should focus on crosscutting generic competencies, such as analytical abilities (for effective use of both evidence and ethical deliberation in decision making), leadership and management capabilities (for efficient handling of scarce resources in conditions of uncertainty), and communication skills (for mobilisation of all stakeholders, including patients and populations)” (Frenk et al., 2010, p. 1951).

Lancet commission recommendations

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Day-long lectures from performance improvement nurses and physicians addressed following: Structure and engagement of nurses in performance improvement activities, alignment of those with organizational strategic goals, exploration of process for improving issues of falls, pressure ulcers, nursing training and retention efforts. Tour of the highly efficient and integrated Diabetic Care Center served as an example of highly efficient care provision model where all diagnostic, treatment, and education activities are housed in one location. Tour and discussion of clinical monitoring systems center, a highly integrated IT platform capturing operations of the hospital in real time. Lectures and tours of the hospital units illustrated integration of Korean traditional medicine with Western treatment modalities. Tour of the hospital. Formal discussion with chief nursing officer, directors, and managers addressed quality improvement/process, improvement initiatives, nursing ratios, nursing roles, nursing education, impact of shift work on retention, efforts to integrate newly graduated nurses into workplace, burnout, lateral violence.

Formal visit to headquarters. Lectures and discussions on the efficacy and efficiency of electronic claims review and fast reimbursement processes, health care resources management and the democratic process for approval of new services. Highly integrated IT systems safeguarding patients' health are discussed and demonstrated.

Formal day-long visit to headquarters. Lectures and discussions on the sources of financing and contribution system for universal health care provision and its influence on the development of a robust primary health care sector, decisions on depth and breadth of coverage.

Immersion program

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Overview of Korean Health Care System (Lecture) & Role of Nurses in South Korea (Lecture)

CNL Simulations Designed for CNL students and based on CNL competencies.

Oh Jung-Ok Skin Rehabili-Center Clinical Lab and Academy (Oh, n.d.)

Public Health Center, Mapo-gu (Mapo-gu Office, 2010)

Organizations

Table 1 (continued)

grafts in burn patients • skin peripheral neuropathy • diabetic care for cancer patients • lyphedema • circulation for patients with paralysis

■ 1st grade [top honors] ● Public Health Services: ○ Prenatal Health ○ Infant/Mother Clinic ○ Vaccination Clinic ○ Oral Health Center (dental) ○ Mental Health Welfare Center ○ Venereal Disease Clinic ○ Tuberculosis Clinic ○ Physical Fitness Evaluation ○ Smoking Cessation Clinic ○ Nutrition Clinic ○ Alcohol Abuse Clinic ○ Center for Dementia ○ Rare-disease Support Services ○ Management of Chronic Diseases ○ Restaurant Food Safety Management ○ Epidemic Disease Monitoring Established in 1999 Developed Skin Rehabilitation Nursing Therapy for management of:

Organizational functions

Clinical Prevention and Population Health for

Organizational and Systems Leadership (Essential 2.1–2.8)

Organizational and Systems Leadership (Essential 2.1–2.8)

Quality Improvement & Safety (Essential 3.1–3.11)

Clinical Prevention and Population Health for Improving Health (Essential 8.2)

Background for Practice from Sciences and Humanities (Essential 1.3–1.4)

Clinical Prevention and Population Health for Improving Health (Essential 8.1–8.6)

CNL competencies

“Promotion of interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams. Alongside specific technical skills, interprofessional education should focus on crosscutting generic competencies, such as analytical abilities (for effective use of both evidence and ethical deliberation in decision making), leadership and management capabilities (for efficient handling of scarce resources in conditions of uncertainty), and communication skills (for mobilisation of all stakeholders, including patients and popula-tions)” (Frenk et al., 2010, p. 1951). “Interdependence is a key element in a systemic approach because it underscores the ways in which various components interact with each other, without presupposing that they are equal. As a desirable outcome, interdependence in education also involves three shifts: from isolated to harmonised education and health systems; from stand-alone institutions to worldwide networks, alliances, and consortia; and from self-generated and self-controlled institutional assets to harnessing global flows of educational content, pedagogical resources, and innovations.” (Frenk et al., 2010, p. 1952). “Expansion from academic centres to academic systems, extending the traditional discovery-care-

“Expansion from academic centres to academic systems, extending the traditional discovery-careeducation continuum in schools and hospitals into primary care settings and communities, strengthened through external collaboration as part of more responsive and dynamic professional education systems” (Frenk et al., 2010, p. 1952).

Lancet commission recommendations

(continued on next page)

Innovations in providing comprehensive health care needs assessment and management to

Various designations of hospitals, role of universal health care coverage, role of primary care. Role comparison between nurses in South Korea and the U.S.

Four simulations developed to distinguish the CNL role from manager, educator, and preceptor. Illustrated system- level issues and CNL role in addressing them and CNL role in leading the team in resolving ethical dilemmas with patient care. Lateral and horizontal integration of care illustrated.

Evidence-based alternative modalities for treating burn patients.

Tour of the faculty. Lecture on structure and functions of public health center; integration of diagnostic, treatment, and educational efforts housed in one location; role of primary health in population health management; robust primary health as a cost containment strategy.

Immersion program

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“As a valued outcome, transformative learning involves three fundamental shifts: from fact memorisation to critical reasoning that can guide the capacity to search, analyse, assess, and synthesise information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and from non-critical adoption of educational models to creative adaptation of global resources to address local priorities.” (Frenk et al., 2010, p. 1952). “Adoption of competency-based curricula that are responsive to rapidly changing needs rather than being dominated by static coursework. Competencies should be adapted to local contexts and be determined by national stakeholders, while harnessing global knowledge and experiences. Simultaneously, the present gaps should be filled in the range of competencies that are required to deal with 21st century challenges common to all countries—e.g., the response to global health security threats or the management of increasingly complex health systems” (Frenk et al., 2010, p. 1951). “A case can be made that all students preparing to enter the health professions should be exposed to the humanities, ethics, social sciences, and notions of social justice to perform as professionals and to join in public reasoning as informed citizens” (Frenk et al., 2010, p. 1946).

education continuum in schools and hospitals into primary care settings and communities, strengthened through external collaboration as part of more responsive and dynamic professional education systems” (Frenk et al., 2010, p. 1952).

Lancet commission recommendations

Addressed ethics in nursing in connection to the CNL role.

Description and examples from CNL practice.

Visit and lecture in 10,000 sf. simulation laboratory (recently expanded to 14,438 sf.), housing 32-bed medical surgical unit, ICU, ED, maternity suite, small apartment for community care education. Preparation for CNL simulations.

Lecture and demonstration of taping methodology in treating musculoskeletal issues.

population 65 years and older in Seoul Metropolitan area through home care visits.

Immersion program

Note: ICUs = intensive care units; CAU Hospital = Chung-Ang University Hospital; IT = information technology; CNL = clinical nurse leader; ED = Emergency Department; MSN = Master's of Science in Nursing.

Master's Level Nursing Practice (Essential 9.15)

All MSN essentials and CNL competencies reviewed

CNL Competencies (Lecture)

Ethics in Nursing (Lecture)

Clinical Prevention and Population Health for Improving Health (Essential 8.2)

Complementary and Alternative Musculoskeletal Therapy in Nursing (Lecture) Simulation Overview at CAU (Lecture) & Simulation for CNL Students (Lecture)

CNL competencies Improving Health (Essential 8.3 and 8.6)

Organizational functions

Welfare and Health: Home Visiting Program in Seoul Metropolitan Government (Lecture)

Organizations

Table 1 (continued)

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via two questionnaires: one addresses finances, technology, efficiencies of care, and comparison of health systems, the other addresses the simulations and changes in the students' understanding of the CNL role. This article, the first in a three-part series, contextualizes our immersion program in the literature on study abroad for nursing students, connects it with CNL competencies, and describes the innovative aspects of the South Korean health care system. Part 2 will detail the course pedagogy and curriculum. Part 3 will provide a review and analysis of how nurse educators can navigate the logistical complexity of planning an immersion program for graduate students, with an emphasis on marketing, finance, and operations.

2009), the shift in participants' understanding of their culture and foreign cultures of interest is more subtle (Harrowing, Gregory, O'Sullivan, Lee, & Doolittle, 2012) and deserves more thorough analysis both in the literature and in practice. In addition to developing students' cultural awareness, undergraduate immersion programs are frequently designed to teach and provide opportunities to practice clinical and psychomotor skills (Ahn et al., 2015; Carpenter & Garcia, 2012; Cummings, 1998). This is frequently juxtaposed to programs which emphasize the goal of comparing and understanding health care systems and the role of nurses in those systems (Beeman, 1991; Birchfield, Dvorak, Scully, Haas, & Duberley, 1991; Colling & Wilson, 1998; Goldberg & Brancato, 1998; Keogh & Russel-Roberts, 2009; Lindquist, 1984; Owens, 2012). Fewer programs analyse the sociocultural, political, historical, and economic influences that have created the health care system in each nation (Ahn et al., 2015; Cotroneo et al., 1986; Duffy, Harju, Huittinen, & Trayner, 1999; Tabi & Mukherjee, 2003).

Literature review International immersion programs provide students with short-term educational experiences in a foreign country. Also known as short-term study-abroad programs, they are distinct from student exchanges that are generally a semester long and frequently replace courses at students' home institution with courses of equivalent weight and scope at a foreign university. During an international immersion program, students study for a short time under the auspices of their home institution and may receive curricular credit while doing so (Duffy, Farmer, Ravert, & Huittinen, 2005). Characteristically, immersion programs emphasize formal and informal experiential learning over the primarily didactic approach of traditional university courses (Levine, 2009).

The socioeconomic perspective From the socioeconomic perspective, immersion programs can be broadly divided into two groups. The first group seeks to understand cultural inequities by visiting other countries and learning about communities and/or health care systems that are underdeveloped or allocate resources among their citizens unevenly (Koskinen et al., 2009; Sullivan & Bettger, 2018). The second group seeks to understand highly developed health care systems that allocate resources potentially more equitably (Baernholdt, Drake, Maron, & Neymark, 2013; Birchfield et al., 1991; Duffy et al., 1999; Goldberg & Brancato, 1998). These immersion programs offer students from high-income countries who visit countries with highly developed health care systems unique opportunities such as (a) comparing health care financing structures, differences in system efficiency, and the integration of information technology (IT) systems; (b) understanding how to improve access to care; and (c) observing how efficacious primary care delivery can alter disease trajectory for patients and affect health care costs (Baernholdt et al., 2013; Birchfield et al., 1991; Duffy et al., 1999; Keogh & RusselRoberts, 2009; Maas, 2011; Scully, Birchfield, & Munro, 1998). These kinds of immersion programs allow students to engage in nuanced comparison due to the countries highly approximated systems and resources. Thus systems level lessons are more easily translated to student's native systems than when they travel from high-income countries to low income countries.

Historical review of study-abroad programs for nursing students Study-abroad programs for nurses and nursing students have been documented in the literature since at least 1978 (Allen, 1978; Levinson, 1979). Early study-abroad and immersion programs for nurses and nursing students focused on comparative health care systems, offering insight on how the U.S. health care system could be improved (Allen, 1978; Cotroneo, Grunzweig, & Hollingsworth, 1986; Levinson, 1979; Lindquist, 1984). Since that time, however, the focus has shifted. Over the past 30 years, short-term immersions have increasingly been created by undergraduate nursing programs with the primary goal of developing students' cultural awareness (Leinonen, 2006), competency in providing cross-cultural care, and opportunities for charitable service, also known as service-learning (Evanson & Zust, 2006; Johanson, 2006; Nash, 2008). Based primarily on Leininger's theory of transcultural nursing (Leininger, 1978), these programs have emphasized cultural competencies ranging from cross-cultural health needs assessment (Sullivan & Bettger, 2018) to improving provider sensitivity and awareness of culturally specific health beliefs and practices (Button, Green, Tengnah, & Baker, 2005; Carpenter & Garcia, 2012; Hern, Vaughn, Mason, & Weitkamp, 2005; Owens, 2012; Ruddock & Turner, 2007; Wallace, 2007). However, despite the importance of teaching cultural competencies in nursing, this work is not without risk, as several authors have noted. Embedded in the current practice of many educational and professional immersion programs and exchanges are disturbing patterns of colonialist discourse, including paternalism, cultural essentialism, and cultural voyeurism (Burgess, Reimer-Kirkham, & Astle, 2014; Finn & Coast, 2017; Racine & Perron, 2012). Much of traditional nursing pedagogy is rooted in essentialist understandings of culture. Essentialism assumes cultures and cultural identities to be homogenous and uniform in such a way that stereotyping becomes virtually inevitable (Gray & Thomas, 2005). Essentialism, however, fails to acknowledge the dynamic and heterogeneous nature of cultural groups and individual identities and the complex social, economic, political, and historical forces that have shaped their past and current experiences (Duffy, 2001; Gray & Thomas, 2006; Gregory, Harrowing, Lee, Doolittle, & O'Sullivan, 2010; Racine & Perron, 2012). Although immersion programs for undergraduate nursing students are frequently promoted in the literature as transformative, life-changing experiences (Charles, 2015; Levine,

International immersion programs for graduate nursing students Comparative analysis of international health care systems and shared learning about health care policy are critically important in the light of the increasing complexity and interdependence of health systems and the demographic and pandemic threats to the stability of such systems (Frenk & Gómez-Dantés, 2002). Sharing how other health care professionals manage these concerns (i.e., best practices and pitfalls for a given population) offers opportunities to develop a more thorough evidence base and promote innovation (Frenk & Gómez-Dantés, 2002). This work is particularly appropriate for students pursuing a Master of Science in Nursing (MSN). However, few articles have been published in the U.S. literature on the engagement of graduate nursing students in international immersion programs. Further, those articles offer divergent views: some advocate building cultural knowledge (Shieh, 2004; Smith-Miller, Leak, Harlan, Dieckmann, & Sherwood, 2010); others promote a multifaceted comparative understanding of health care systems internationally (Birchfield et al., 1991; Maas, 2011; Ter Maten & Garcia-Maas, 2009). The few immersion programs (undergraduate and master's) that have promoted the exploration and understanding of foreign health care systems have done so by means of clinical observation and nursing 5

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lectures (Duffy et al., 1999; Maas, 2011; Tabi & Mukherjee, 2003). This pedagogical approach limits students' exposure almost exclusively to a nursing perspective on clinical care delivery. As nurses' roles have expanded in both community and hospital settings (e.g., executive leadership, administration, quality improvement, risk management, and informatics), nursing educators must abandon traditional silo thinking for a systems-level, comprehensive examination of how health care services are coordinated. For example, engaging with and learning from stakeholders in financing, informatics, and quality improvement will encourage nurses to develop new ways of thinking and communicating about systems-level improvements and patient outcomes. Cross-disciplinary knowledge and associated skills increase nurses' ability to be effective change agents in health care systems. The importance of such education is underscored by the report, “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World,” which was issued by The Lancet's Commission on Education of Health Professionals for the 21st Century (Frenk et al., 2010). The report makes clear the importance of breaking down professional silos to develop “leadership and management capabilities (for efficient handling of scarce resources in conditions of uncertainty)” (Frenk et al., 2010, p. 1951). The commission's goal for health professionals is to move beyond specialty education and embrace one's complementary “roles as accountable change agents, competent managers of resources, and promoters of evidence-based policies” (Frenk et al., 2010, p. 1951). The report further advocates “a new professionalism that uses competencies as the objective criterion for the classification of health professionals, transforming present conventional silos” (Frenk et al., 2010, p. 1951).

third leading cause of death in the U.S. (Centers for Disease Control and Prevention, 2015). The framework of the CNL curriculum was designed to ameliorate the issues described above. It comprises three domains: nursing leadership, clinical outcomes management, and care environment management (AACN, 2013). Within those domains, additional clusters of foci are delineated. For care environment transformation in particular, special attention is given to team coordination, health care finances and economics, health care systems and organizations, health care policy, quality management, risk management, patient safety, and informatics. All of these components are featured in our immersion program. Why visit South Korea? Health care systems in the U. S. and South Korea share similar challenges: aging populations, demands for broader coverage of services, meeting the medical needs of underserved rural areas, fee-forservice payment systems that incentivize higher utilization of services, nursing shortages, and mandatory participation in insurance coverage (Fried & Gaydos, 2012; Knickman & Snell, 2002; Pyo, 2009; Song, 2009). Despite these challenges, in a process that spanned 12 years, South Korea achieved universal health care coverage in 1989 (Na & Kwon, 2015). By contrast, the U.S. still struggles to provide comprehensive care nationwide. In addition, South Korea became a single payer system in 2000 by merging existing medical insurance societies (Kwon, 2009). The successes and challenges of South Korea's rapid expansion of coverage and the 40-year development of its health care industry provide an ideal context to examine operational mechanisms and underlying values, priorities, stakeholders' financial motivations, and the significance of unified political will, all of which affect the quality of health care delivery. As the long-standing, divisive debate continues in the U.S. about the merits and sustainability of a universal health care system, the first author created this immersion program to provide future nursing leaders with an international perspective on health care and an opportunity to benchmark their own system (Maas, 2011). The Comparative Health Care Immersion Program in South Korea provides an invaluable opportunity to examine the curricular components needed for systematic care transformation, as envisioned in the CNL role. The program examines financing, especially how gross domestic product is allocated in a universal single-payer reimbursement system, how informatics is used to monitor and improve quality of care delivery, what processes lead to efficiencies of care, and the role of primary and complementary medicine in population health.

International immersion programs for CNL students To the best of our knowledge, this is the first article to address the use and import of international immersion programs on the education and development of MSN CNL students. As the American Association of Colleges of Nursing (AACN, 2013) makes clear in its “Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice,” clinical nurse leaders must “develop an understanding of how health care delivery systems are organized and financed (and how this affects patient care) and identify the economic, legal, and political factors that influence health care” (p. 10). In an increasingly globalized world, this requires that nurses benchmark their health care system against others through international experiences that allow them to reflect on their system's strengths and weaknesses (Maas, 2011). Nurses too should study foreign health care systems to fully understand how “a country's history and philosophy” and “social and political climate” influence both the nurse's role and the provision of health care (Birchfield et al., 1991, p. 1132; Duffy et al., 1999). Examining health care through the lens of public policy can embolden MSN students to become change agents (Birchfield et al., 1991).

Financing health care To examine how the South Korean government finances and operates its universal single-payer insurance system, students visit two agencies that govern utilization of and payment for health care provisions: the NHIS and HIRA (Figs. 1, 2, & 3). South Korea has dramatically improved health outcomes (e.g., life expectancy and mortality) since the inception of universal health care coverage, (Kwon, 2009). Thus the mechanisms of health care operations are particularly instructive for CNL students because, as CNLs, they will assume responsibility for such improvements in the U.S. health care system. During these visits CNL students are exposed to a wide array of relevant financial topics: the role of government in regulating fees for medical services; different reimbursement mechanisms that lead to disparities in utilization of services; systems for selection, review, and approval of new services, medication, and equipment; efficient processes for claims review; and the role of civic groups and labor unions in the democratization of public policy. Knowledge of insurance payment structures, the utilization review process, the reasoning behind approval and denial of claims, and the dimensions of universal health care coverage (World Health Organization, 2018) elucidates the role of

Introduction to the CNL role The CNL role was designed to address issues that result from fragmentation of care, inefficient processes, poorly integrated systems, rapid staff turnover, and staff disengagement (AACN, 2013). Patients, health care workers, health care organizations, and the health care industry overall are negatively affected by work performed in poorly designed environments of care. Although the U.S. health care industry spends 31% more per capita than the next highest country, Switzerland, and nearly 50% more than most wealthy countries (Sawyer & Cox, 2018), it is consistently ranked the lowest overall among industrialized nations in mortality related to medical care, infant mortality, healthy life expectancy at age 60, access due to cost-related problems, efficiency, and equity (Davis, Stremikis, Squires, & Schoen, 2014). Each year in U.S. hospitals, between 210,000 and 400,000 people die because of medical errors (James, 2013), which are considered to be the 6

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conversations with HIRA leadership and in-depth debriefings with faculty elaborate the role of IT in shaping quality care delivery, ensuring patient safety and clinician accountability, and emphasizing why CNLs need to participate in the creation of functional and efficient IT systems in their organizations. Efficiencies in health care delivery The third major goal of the immersion program is to examine efficiencies in health care delivery. Specifically, modifying the care environment by creating efficient processes that allow clinicians to function at the highest level of their education and experience is a goal that CNLs have championed for a decade (Bender, Connelly, Glaser, & Brown, 2012; Eggenberger, Garrison, Hilton, & Giovengo, 2013; Murphy, 2014; Ott et al., 2009; Smith, Manfredi, Hagos, DrummondHuth, & Moore, 2006; Sotomayor & Rankin, 2017; Wienand et al., 2015; Wilson et al., 2012). Hospital visits are carefully chosen to illustrate factors that affect nursing practice and efficient processes. We routinely visit three hospitals in Seoul, South Korea: two that offer Western medical services and one that offers both Western and traditional Korean medical services. In addition, students visit a private nurse-led skin rehabilitation center and a large public health center (Table 1).

Fig. 1. South Korean Health Care System Organizational Structure. Adapted from “Health Insurance System” by Korea Biomedicine Industry Association (KoBIA) (2018). Retrieved from http://www.kobia.kr/e_sub02/ sub01_2.php. Copyright 2018 by KoBIA.

utilization management, case management, and insurance eligibility workers role in the U.S. health care system. Exploring the roles of these professionals in assuring safe, timely and cost effective patient care through the lens of South Korean health care financial and information technology systems serves several goals. It gives students perspective on the synergy of purpose between these roles often invisible to bedside nurses, nuanced differences, their salience and role delineation. In the context of CNL education, conversations illustrate purpose and process for collaboration to achieve unit level and organizational goals when laterally integrating care, effectively planning for discharge, and safeguarding their organization's financial security. South Korea's Health Insurance Policy Deliberation Committee, which operates under the Ministry of Health (Fig. 4), approves or denies new services and equipment, among other responsibilities. Chaired by the Vice Minister of Health and Welfare, the committee's 24 members include citizens, providers, public agencies, and technical experts (Kwon, 2015; Oh, Ko, Alley, & Kwon, 2015). Discussing the merits of the committee's composition and processes and examining the value of its multidisciplinary membership and their diverse perspectives is instructive for CNL students. They can appreciate not only the mechanisms of insurance operations but also the importance of stakeholder perspectives, harmony of expertise, and the balance of power and interests. Of particular interest is the formal power of citizens on this committee. All of these ideas can inform practice whether CNLs are introducing a performance improvement initiative or advocating increased patient involvement in the design and implementation of departmental policy.

Hospital visits The first hospital, Chung-Ang University Hospital, an 840-bed facility, has been recognized as the best emergency medical center for 8 consecutive years and the best thyroid center in South Korea (Kim, 2018). Students visit several departments to observe care integration processes and participate in panel discussions with nursing leaders. During panel discussions students engaged hospital leadership on topics such as nurse-to-patient ratios, family caregiving responsibilities for all activities of daily living, new graduate training and attrition rates, career ladder, and hospital quality improvement initiatives. Comparative analysis highlights the strengths and shortcomings of operational nursing practice in both the U.S. and South Korea and gives CNL students perspectives on influences from micro, macro, and mesosystems on nursing operations and quality care delivery. The second, Asan Medical Center (AMC, 2017), in Seoul, with 2700 beds is the largest hospital in South Korea. Since its inception in 1989, AMC has utilized rigorous, formal infection control and quality improvement programs by investing in employee development and information technology infrastructure. To this end, AMC created Asan Medical Information System (AMIS) in 1989 with the goal to become a paperless hospital, facilitate transparent and timely communication, monitor and reduce medical errors, facilitate resource planning, remain efficient, effective, and patient centered, and continue to ensure privacy and security (Ryu et al., 2010). One component of AMIS is of special interest: the integrated patient monitoring system. This system integrates “inpatient bed management, outpatient wait scheduling system, an operation theater management system, and an integrated laboratory reservation monitoring system” (Ryu et al., 2010, p.195). Their continuous commitment to patient safety and efficient care delivery led to AMC's formulation of South Korea's first Task Force for Quality Improvement of Medical Care (AMC, 2017). During the visit, students tour hospital departments including the patient monitoring system area, the comprehensive diabetes treatment clinic, and the thyroid center. Additionally, during lectures on the medical center campus led by AMC clinicians, students study quality measurements and initiatives, and nursing's role in providing and improving clinical care and conducting research. Discussions following the site visit address the translational science process for learning and adapting efficiency processes to CNL students' care environment back home.

Informatics The second major focus of the immersion program is improvement in patient care outcomes via optimal utilization of informatics systems in health care delivery. Relying on an efficient IT platform, HIRA's centralized claims review system allows for monthly claims submission by all insured providers in South Korea. Evidence-based guideline algorithms are used in the review process. Once reviews are completed electronically, the NHIS is alerted to issue payment to providers, which takes roughly 2 weeks after claim submission (Na & Kwon, 2015). Outlier cases are submitted for medical and nursing review. In addition to HIRA's reimbursement management informatics platform, its Drug Utilization Review service platform (Fig. 5) showcases the ability of IT systems to prevent patient harm by synchronizing the medication prescriptions of all providers in South Korea. Once physicians prescribe medication, the information is immediately forwarded to HIRA, which then checks for potential harm, precautions for age and pregnancy, prescription duplication, or adverse drug interactions between old and new medications. This system achieves several goals: fast and safe medication reconciliation, avoidance of duplicate prescriptions, large scale objective medical records review, fast payment delivery, and accountability and transparency of the payment process. Lectures and

Korean medicine hospital The third hospital, Kyung Hee University Medical Center, offers the 7

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Fig. 2. Overview chart of the health care system. From “Republic of Korea: Health System Review” by Chun, Kim, Lee, and Lee (2009), Health Systems in Transition, 11, p. 25. Copyright 2009 by World Health Organization.

students insight into the purpose and value of traditional Korean Medicine (KM). This hospital, a 400-bed facility, provides Western and comprehensive KM treatments in standard medical specialties, ranging from gastroenterology to oncology, and dentistry (Kyung Hee University Medical Center, 2015). Korea's NHIS is the first in the world to reimburse providers for comprehensive KM treatments (Lim, 2013). In U.S. clinical practice, most Oriental medical services are not insured. However, in South Korea KM is widely incorporated into treatment modalities and insured by NHIS. The number of claims for KM treatments submitted to the NHIS increased from 1.6 million in 1990 to 91.4

million in 2010 (Lim, 2013). In the first quarter of 2012 alone roughly 24 million people in South Korea used KM to treat a wide variety of diseases (Lim, 2013). At Kyung Hee University Hospital, students tour several departments, including an herbal compounding pharmacy. Additionally, clinicians and professors of KM lecture students on research initiatives and treatment regimens. Oh Jung-Ok Skin Rehabili-Center Clinical Lab and Academy Complementing their visit to Kyung Hee University Medical Center, the students also visit the Oh Jung-Ok Skin Rehabili-Center Clinical Lab 8

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Fig. 3. National health insurance operation system. From “National Health Insurance Operation System” by National Health Insurance Service (2010). Retrieved from http://www.nhis.or.kr/static/html/wbd/g/a/ wbdga0401.html. Copyright 2010 by National Health Insurance.

and Academy where Director Jung Ok Oh shares her innovative dermatological and circulatory treatments for patients with scarring, lymph edema, and peripheral neuropathy, among other conditions. Her dermatologic modalities are designed to significantly increase the

elasticity and flexibility of the skin allowing for faster post-surgical healing. In visiting this center and Kyung Hee University hospital, CNL students learn the role of complementary medicine, its scientific basis, and the value patients and providers ascribe to it. The goal of these

Fig. 4. Performance assessment system overview. From “Using Performance Information in National Health Insurance, Korea” by Kim (2016), p. 7. Retrieved from https://www.slideshare.net/OECD-GOV/usingperformance-information-in-national-health-insurance-korea. Copyright 2016 by Organization for Economic Co-operation and Development. 9

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Fig. 5. Process for inspection. From “Health Insurance Review and Assessment Service” by Health Insurance Review and Assessment Service (2013), p. 22. Retrieved from https://www.hira.or.kr/ eng/news/01/__icsFiles/afieldfile/2013/09/06/2013_HIRA.pdf. Copyright 2013 by Health Insurance Review and Assessment Service.

sporadic, limiting student exposure to practice models. Second, other health care workers (e.g., social workers, case managers, and clinical nurse specialists) often assume responsibility for components of CNL work, which causes role confusion in the clinical environment. During our immersion program, students participate in four simulations that are designed to illustrate the breadth and depth of CNL competencies. Five major competency areas as defined by AACN (2013) essentials, are explored (Table 2). In the first scenario, a patient of advanced age with a do-not-resuscitate order whose family desires to proceed with treatment, the CNL role is distinguished from the roles of physician and social worker. The second scenario, in an operating room, presents lateral violence between medical and nursing staff and illustrates how the CNL engages in horizontal leadership and promotes healthy work relationships. In the third scenario, a local hospital is repeatedly on diversion mode because of inefficient patient flow through the hospital. Role delineation between managers and CNLs from various departments, system level improvements, and conflict management are explored. Students are asked to reflect on the complexities involved in providing continuity of care and how “bottom-up leadership” can improve overall institutional performance. The final case study explores manager, educator, and CNL roles in a scenario of conflict between a preceptor and a newly graduated nurse in the first 3 months of training. Collectively, these scenarios offer students the opportunities to explore the value of microsystem-based leaders engaging in systematic root cause analysis, review of evidence-based practice, and innovations in transforming the clinical environment. Improved communication and efficiencies of care can ultimately lead to improved patient outcomes, as seen in these scenarios. Simulations are preceded by faculty lectures on relevant CNL competencies, CNL operationalization in clinical settings, and elucidation of the unique nature of the role. Faculty from CAU co-created the simulation scenarios, trained simulation laboratory technicians, and provided intellectual and operational leadership during the simulations. The four simulations are conducted concurrently and video recorded for the students' review. In the orientation session, 16 of 41 students chose

experiences is not only to broaden students' awareness of Korean approaches to health care but also to equip them for greater patient advocacy. Such advocacy is facilitated by firsthand observations, conversation with primary investigators and clinical experts, and group debriefings on how this new knowledge can be further analyzed and used. This advocacy will be called upon when patients want to know about alternative treatments or when explaining to clinical peers how the use of these treatment modalities might contribute to improved outcomes. Primary care clinic Finally, the group visits Public Health Center Mapo-gu, a comprehensive, urban public health center. Here students observe how the Korean national health care policy is operationalized to manage public health. They observe and receive lectures on the use of multidisciplinary and interprofessional collaborations in primary care to improve population health outcomes for vulnerable groups and the population at large. Visiting this center illustrates how communal illness can be strategically prevented (e.g., vaccinations, prenatal care, food safety), mitigated (e.g. venereal disease screening, early tuberculosis detection, physical therapy), and chronic diseases managed through decentralized, easily accessible community-based care. Historically, health care education has prioritized teaching from a tertiary care perspective rather than a primary care, community-based care perspective, which has led to a lack of health care workers with appropriate training in these critical areas (Frenk et al., 2010). The CNL role was conceptualized to function across a continuum of care. Accordingly, students should experience and reflect on the structure of systems committed to preventing disease and improving population health outcomes. Simulation training Engaging MSN students in simulation training that illustrates CNL competencies and the uniqueness of the role is necessary for these reasons. First, implementation of the CNL role in the U.S. has been 10

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Table 2 Simulation Scenarios Case Scenario

Roles

MSN and CNL Competencies (AACN, 2013)

Uniqueness of the CNL role

A patient of advanced age with dementia, with signed DNR orders, is refusing care. Family members are advocating for continuation of care.

• Actors: ○ Patient ○ Daughter ○ Social worker ○ Chaplain ○ Physician • Learners: ○ Primary RN ○ Secondary RN ○ CNL • Actors: ○ Plastic surgeon ○ OR RNs x2 ○ Nurse Executive ○ Medical director • Learners: ○ CNLs x3 ○ Nurse Manager

MSN Essential 7: Interprofessional collaboration for improving patient and population health outcomes. 7.3 Facilitate collaborative, interprofessional approaches and strategies in the design, coordination, and evaluation of patient-centered care. MSN Essential 9: MSN-level nursing practice. 9.15 Engage individuals and families in making quality of life decisions, including palliative and end-of-life decisions.

As a lateral integrator of care, the CNL organizes the ethics committee to discuss patient and family wishes. Although social workers may serve this function in absence of CNLs, CNLs, as microsystem leaders, are accountable for quality and outcomes of care delivery for patients. Their daily presence on the unit facilitates frequent and timely communication between patients and family and seamless integration of care.

MSN Essential 2: Organizational and system leadership 2.7 Collaborate with healthcare professionals, including physicians, advanced practice nurses, nurse managers, and others to plan, implement and evaluate an improvement opportunity. MSN Essential 4: Translating and integrating scholarship into practice 4.7 Lead change initiatives to decrease or eliminate discrepancies between actual practices and identified standards of care. MSN Essential 2: Organizational and system leadership 2.2 Assume a leadership role of an interprofessional health care team with a focus on the delivery of patient - centered care and the evaluation of quality and cost-effectiveness across the healthcare continuum. 2.4 Demonstrate business and economic principles and practices, including cost- benefit analysis, budgeting, strategic planning, human and other resource management, marketing, and value - based purchasing. MSN Essential 7: Interprofessional collaboration for improving patient and population health outcomes. 7.5 Demonstrate a leadership role in enhancing group dynamics and managing group conflicts.

Nurses commonly experience lateral violence (Rainford, Wood, McMullen, & Philipsen, 2015). This case illustrates the role of CNLs in implementing evidence-based practice to transform the culture of the work environment. The CNL designs the process to implement TeamSTEPPS for patient-centered communication between the interdisciplinary team.

Lateral violence between surgeon and operating room nurses.

A backlog in the ED was identified a • Actors: ○ ED manager year ago. Problems persist even ○ ICU manager though a new electronic bed ○ Director placement system has been ○ Hospitalist operational for 6 months. The director of critical care holds a • Learners: ○ PACU manager meeting with managers of the ○ PACU CNL ICU, PACU, and ED and rashly ○ ED CNL designates the PACU manager ○ ICU CNL as team leader to resolve the ○ Telemetry CNL problem. ○ Psychiatry CNL

• Actors: Preceptor of a newly graduated ○ Preceptor nurse appraises the young ○ Newly graduated nurse’s performance as meeting nurse all competency requirements. Newly graduated nurse • Learners: ○ CNL perceives her own performance ○ Manager as inadequate and senses judgement and disapproval from her preceptor. New nurse seeks to discuss her performance with the unit manager.

Patient flow significantly contributes to health outcomes and has financial ramifications to hospitals. In this case, CNLs demonstrate the quality improvement process by assessing the problem, reviewing evidence-based practice, designing an intervention, and evaluating its effectiveness. Conflict resolution between managers is explored by using a data driven process to solve problems, using TeamSTEPPS methodology and focusing on patient centered care. Bottom-up leadership in designing new workflows is examined, and CNL collaboration across related microsystems is highlighted. Differences between CNL, manager, and director roles are explored. CNL and manager discuss the feedback process during MSN Essential 2: Organizational and system leadership orientation of newly graduated nurses. 2.8 Participate in a shared leadership team to make recommendations for improvement at the micro-, meso-, or CNL conducts an assessment to ascertain if this is systemic problem, reviews orientation guidelines, and macro-system level. determines if a more formal process for MSN Essential 3: Quality Improvement and Safety 3.7 Demonstrate professional and effective communication communicating competencies to newly graduated nurses is necessary. If so, CNL collaborates with skills, including verbal, non-verbal, written, and virtual education department, providing feedback and abilities. recommendations. MSN Essential 9: Master’s – Level Nursing Practice This case illustrates the difference between manager, 9.5 Demonstrate the ability to coach, delegate, and supervise healthcare team members in the performance of CNL, and educator roles. nursing procedures and processes with a focus on safety and competence.

Note: MSN = Master of Science in Nursing; CNL = clinical nurse leader; DNR = do not resuscitate; RN = registered nurse; OR = operating room; TeamSTEPPS® = Strategies and Tools to Enhance Performance and Patient Safety, an evidence-based set of tools to improve communication and teanmwork between health care professionals; ED = emergency department; ICU = intensive care unit; PACU = post-anesthesia care unit.

to be actors and were assigned a team with whom they prepared in advance to perform the assigned simulation. Following the students' debriefing of the scenarios, a class debriefing is conducted with all faculty present. Further details are provided in Table 2.

implemented to improve care outcomes. This prepares them for leadership that is rooted in a more comprehensive understanding of what is possible in care improvement. Providing a similar learning experience in the U.S. has been difficult because our health care system is fragmented and the application of system-level advances (e.g., in finances and technology) to improve efficiency is slow and inconsistent across regions. Thus, an immersion program such as ours not only fills a gap in current training but stimulates students' imagination on the possibilities for quality improvement initiatives in their work as future CNLs. Our hope is that this immersion program is shared and replicated.

Conclusion Our Comparative Health Care Immersion Program in South Korea fills a gap in current MSN CNL preparation: It gives students the opportunity to experience an advanced health care system in a foreign country and to benchmark our U.S. system. This opportunity is important for two reasons. First, CNL students learn how interprofessional and multisystem coordination can be implemented in quality improvement endeavors, which has been difficult in the U.S. because the CNL role has not been implemented in many regions. Second, CNL students learn how advances in financial, technological, and information systems can be customized to domestic health systems and

Acknowledgements The authors wish to thank former dean of Chung Ang University Dr. Kyung Hee Kim and current director of international immersions Dr. Sang Sook Kim for their leadership and support in organizing immersions over the past few years. Also, thanks to research assistants Tiffany 11

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Livingston, Yvette Melgoza and Tiffany Wong for their consistent and dedicated leadership prior to and during 2017 immersion program. Lastly immense gratitude to Bob Sparacino for multiple edits of manuscripts and Julie Kesterson for thoughtful insights during the revision of the final manuscript. The interpretations and conclusions of this article reflect the authors' views alone, and any errors are our own.

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