1) Environment adjustment

The environmental adaptation was about the participants' adaptation to the characteristics of the rural and remote areas, mostly in farming and fishing areas. The assigned regions were mainly challenging to the CHPs, especially in their initiation state. In particular, the participants who grew up in urban areas had a more difficult time than others. 'Tears' was the representative concept that reflected the difficulty of adjusting to the first assigned environment. The harsh climate made participants feel 'isolated' and 'missed the outside lives'. For example, the 'neon sign' was a symbolic expression of city life. Besides,'feeling threatened' was one of the enormous challenges the participants went through.

There were a lot of briquette accidents. One of our seniors was sleeping with her mother, and they were dead. Because of the briquette. Even the mother and the senior. There were also suicidal accidents. One CHP used the mental health-related medicine 'phenobarbital' to suicide… Since there was no safeguard at that time… some people went through sexual violence from the male community members got married and stayed there for good. (Participant 1)

That place didn't have any toilets, so I had to go to the field. I had to pipe water from the ground to make supper. That made me cry all day. It was more than I imagined. I knew nothing and went there. I expected basic supplies would have been there because it was called a 'health clinic'. (Participant 12)

Most of the participants had a difficult time adjusting to the remote areas. When assigned to island regions, most CHPs avoided them; they expressed they went through a more challenging situation than others. The lack of transportation and resource was the hardest part. However, since the environmental condition was challenging, the community members were desperate to make the CHPs stay in their community.

Since nobody wanted to come, we had to stay at least three years, and if nobody came, it meant we had to stay there for our graves. (Participant 13)

Considering the occupational environment as a positive perspective was related to having the authority to choose the area. When the assigned area was a familiar place like their hometown facilitated the designated area's adaptation. A few respondents perceived the rural area as 'beautiful nature'. They were amazed by the visuals and sounds of nature. In the initial phase, the primary economic industry in rural areas was farming or fishing. The community started early morning, around 4:30 am, which could assume when the patients would visit.

If I go to the village, it looks like seeing a classical picture. The kids had snots on their noses, and people were making dinner by collecting logs. It felt like a different place. It was good. We travel to these places on purpose! I felt like traveling. Ha-ha… When I went to the G area, I intentionally went by the dirt road, which was unpaved for my pleasure. (Participant 3)

2) Work adjustment

CHPs handled preventive care, health education, and health projects. Therefore, the participants had a more comprehensive range of work roles than clinical nurses.'Lack of professional training' and 'discrimination' made it challenging to get used to the CHP work. Respondents emphasized 'education' in this context for professional and self-development. There were workshops and training programs related to advanced clinical knowledge. Some enjoyed learning how to diagnose and prescribe medicine; however, others 'felt discriminated' and ignored by the instructors, who were primarily medical doctors.'Lack of administration support' indicates the lack of support from the official government. Participants felt lonely by not having enough administration support and working separately. Even essential resources (e.g., medicine, paper) were not enough; some CHPs had to borrow and collect recycled papers for prescription sheets.

I had to home visit without any medicine. People don't know us. So they start with "Who are you?". We had to start introducing ourselves. Even the health center staff did not know who we were and was unfamiliar with the CHP program. (Participant 5)

The burden of work was related to 'clinical experiences'. Participants with clinical experience felt less load than their counterparts. The participants felt the most fear when'performing suture', 'performing dressing in wounds', or'making a diagnosis', which was typically a doctor's job. At the same time, clinical performances built up 'confidence' as 'professionals'. The most challenging works were'delivering a baby' and 'acting for emergency issues'. Since these issues were all related to 'life-threatening' problems, the participants expressed the hardship of handling the pressure. There were cases where the CHPs delivered a baby on the bus or unexpected twins. 'The sound of the tractor or motorcycle' was the sound of the 'precursor of emergency cases'.

The sound of the tractor.. even when I was sleeping, if I heard a sound of the tractor, I automatically woke up and said, 'Ah! A Patient!' but then I realized I was at home. Also, when I am at the clinic and hear the sound of the tractor. I get tensed. The motorcycle sound.. I carefully listen to if it will pass by or stop at the clinic. When it's the clinic, the clinic turns into an emergency room. If it gives by… hwww.. it's not an emergency. (Participant 5)

Also, the 'managing community health programs' role led to extra work loading. Unlike clinical nurses, CHPs had to manage 'health-promoting education' like promoting physical activity', opening 'gymnastic programs', or'dance schools'. On the other hand, some CHPs considered this role 'positive' and 'felt autonomous' in their career than their clinical duties and put more 'passion' into these community health programs.

For extra, we had to provide health education or health promotion related programs like 'walking movement' or 'aerobic classes'. I invited gymnastic instructors and taught the community members sports dance, yoga, and stretching for 80 participants. Whenever the clinic was over, the community members gathered in front of the clinic and danced together. I stood up the stairs and guided the group, and the group was dancing and dancing even though they were sweating. It was so much fun. (Participant 11)

3) Community adjustment

Along with adapting to the environment and work,'being a true community member' was another retention factor. Different locations had different community cultures based on regional history. The CHPs needed time to learn about the community members' personal and provincial history. Since the CHPs personally had different unique backgrounds and were higher educated women, there was a distance between the community members, especially among women community members.

Most of the community members called me Chief… But the woman next to me started to call me my name, saying I was the same age as her. I was embarrassed and didn't know what to say. (Participant 4)

Remote areas were unique and related to higher needs for primary health care than other sites. Moreover, remote areas had more complicated histories associated with the national history of South Korea. CHPs who worked in more isolated areas, like in the island areas, described being treated like a 'queen' or a 'celebrity'.

The more remote area you are assigned, the more queen you can be. I was on a faraway island, and the director always called me My highness. (Participant 16)

1) Encountering lifetime crisis

While the CHPs were adjusting and building coping strategies, various lifetime crises came along. There were'stressful events', 'relationship conflicts', and 'work pressure' that led to 'feeling exhausted' and 'powerless'. As a standard narrative, the participants mentioned the first five years of working were the most stressful period at the same time when their children were still young.

In the stage of attachment, my baby didn't want to let go of me. It was a war every morning to go to work. The baby cried like hell. It didn't let me go blocking me from going to work. (Participant 10)

'Stressful events' included health problems and lack of welfare. Three participants suffered severe health problems due to workload, not getting enough sleep, and eating poorly. Even in cancer, the CHPs still had to work with their painful health condition. They also felt embarrassed about not managing their health well while being a health provider.

When I was diagnosed with cancer, we were part-time workers. We didn't have any official leave for illness. So how did I go through it? I had the surgery, got discharged, and stayed with my sister for a day. I returned the next day, rested for two days, and went back to work. (Participant 11)

'Relationship conflict' included the relationship between family, community members, and health officers. The relationship conflict was deeply connected with the multiple roles of the CHPs. They had to be mothers and wives at home while they were the community's leading primary health providers. The CHPs who had children (15 out of 16) especially mentioned the hardship when their children were in the 'attachment stage' aged 0~2 years old and in the 'youth' stage. When the CHP's children were in the stage of youth, they claimed their mother cared more about the community than themselves. Due to the lack of educational resources, the CHPs went through conflicts between their family about 'education' and 'college issues'.

I breastfed all of my three children while I was working in the community health post. Someone to help? Nonsense! It was real. All three. (Participant 2)

My daughter said, 'You only care about the grandmas than me!'. (Participant 4)

Moreover, the CHPs had to deal with the dynamics among the community members. The CHPs mentioned it was hard to consider the community's various needs, mainly when the opinions were divided in the opposite direction.

[To the community members], I turned into a 'yes man'. In any case, I had to say yes. Yes. Yes. That also made me say 'yes' always to my husband and my kids. I think I forgot to express my own opinion. (Participant 6)

'Work pressure' mainly came from the regional health government office while the health system and social status of primary health were changing dynamically in the 1990s. The position of the CHP changed from a special officer position to a regular full-time job. The change of social status made the CHPs stable but with more restrictions and guidelines to follow. Some of the CHPs also were reshuffled to another region without any notice. The elder CHPs felt they lost their authority in managing health programs and administration work. It also led some CHPs to request an earlier retirement.

They said we had done a great job. Great job. But the medical associations, the doctors, wanted us to disappear. We had to hear we would disappear every time we went through the workshop. I hated that. (Participant 12)

2) Coping Strategy 1. Self-effort

To overcome the crisis related to the environment, work, and the community, the CHPs tried to 'improve the poor working condition', 'develop their professional needs', and 'try to be united with the community'. First, some CHPs tried to remodel the community health post themselves. They visited other community health posts to benchmark and made a budget for remodeling.

I saved money to remodel this place [the health post] for ten years. I used cypress for the ceiling and put in so much effort. Even the electricity cords.. because some seniors forget to turn it off… With the money, we saved…. (Participant 2)

Most of the CHPs had more confidence when they made their work strategy. Some CHPs put passion into home visiting care and try to think from a patient-centered perspective. Some CHPs registered extra training courses for professional development like 'hospice training', 'nursing graduate school', and 'nurse practitioner programs'.

I stayed in the health post in the morning. In the afternoon, I went to the field because I had a car and gave the Intramuscular (IM) medicines that were working. I also delivered the medicine to their home with the name tags. (Participant 13)

There was a turning point when the CHPs felt they started to be 'united with the community'. This strongly motivated the CHPs to maintain to stay in the area. At first, the CHPs expressed having an overlapping identity'being a representative of the community members' and'being a member of the government at the same time'. They had role conflict when issues related to the federal policy and the community protested against that. The CHPs who stood on the community members' side got more trust and respect.

The official worker told me to apologize to the mayor. They also told me to agree on every subject with the mayor. They expected me to grab the microphone and insist that I agreed with the mayor. But how could I stay against the community where 99% disagreed with the mayor's opinion. I thought that was betraying. (Participant 8)

Another piece of evidence is that the CHPs were accepted as community members when invited to the community's events like school events, village competition events, and traveling.

I turned out to be the one who has to be with them on every occasion. They invited me to the school's sports events and picnics. The elders invited me when they were going on a travel. I happily went to every event and traveled. I could feel them perceiving me as a community member, not a government officer. (Participant 7)

3) Coping Strategy 2. Social support system

'Supportive system' was the positive enforcement for CHPs dealing with community health issues. It included relationships with the upper-level health officials in the public health center, colleagues in the same cohort, community members, and family. Having positive relationships with the health officials was essential for processing administration-related tasks. One CHP with experience working in the health center represented an ideal mediator between the health officials and the community members. However, most CHPs felt uncomfortable communicating with the health officials.

Representative community members organized the community steering committees (CSC). A good relationship with the community committee, especially the village health workers (VHW), was a significant factor in effectively adjusting to the community and promoting primary health care. This teamwork helped the CHP get closer to the community and effectively apply health education and health promotion activities.

Some participants shared their hard times with their cohort members. CHPs said since the colleagues were distant, it was helpful to each other that they could keep each other secrets. One participant was having annual meetings with their cohort for ten years. Another participant had monthly meetings with the members in the same region. Having a solid membership motivated the CHPs to remain their work.

The majority of the participants were married and had children. Therefore, the life of being a CHP had to interact with life as being a woman. The participants had to manage the community's health while dealing with their own life as wives and mothers. However, it was hard to expect maternal welfare from the federal government. That made the family support more critical for the participants to continue working.

I think it was 1999.. Do you remember it snowed 10 feet? I remember holding my medical kit and my husband pushing down the snow in front of our house. If he pushed the snow down before me, I stepped forward. I think we did that over 30 minutes to reach a patient. (Participant 14)