Abstract

This paper aims to analyze the regulatory structure of nursing in Mexico through its legislation and perspectives of participant stakeholders. A case study was undertaken using qualitative and quantitative data sources, as well as from the review of official documents. The analysis included data from the sources according to the four realms proposed by the Moran & Wood (1993) model. The more advanced realm was the market entry since the state regulates entry through a license of practice. The regulation of competition is weak, showing very reduced areas of autonomous practice. The labor market is offering a wide variety of entry options with clear signs of deterioration. The dominant payment mechanism is salary, showing a structure that incorporates a component that does not impact on pensions at the end of the labor cycle. The regulation of nursing is a component of its professionalization, and as such, it is understood as a multidimensional consolidating process, particularly realms related to the regulation of competition, market structure, and payment mechanisms, in which nursing representatives should play a more active role in the future.

Key words
Nursing; Legislation; Mexico; Health workforce; Health care sector

Introduction

Mexican nursing is going through significant changes. On the one hand, one can observe the increase in training years and practice roles, and on the other, a dynamic labor market but with signs of deterioration¹1 Nigenda G, Ruiz JA, Rosales Y, Bejarano R. Enfermeras con licenciatura en México: estimación de los niveles de deserción escolar y desperdicio laboral. Salud Publica Mex 2006; 48(1):22-29..

While graduated nurses have been training for more than half a century, the production volume has increased exponentially only in the last ten years. The labor market has shown more interest in recruiting licensed nurses to the detriment of lesser educated nursing personnel who dominated the market for decades²2 Gobierno de México. Secretaría de Salud. México: Sistema de Información y Administración de Recursos Humanos en Enfermería [Internet]. [acessado 2019 Jul 2]. Disponible en: https://bit.ly/32NG0pV
https://bit.ly/32NG0pV... . In training, the growth of the private sector in the nursing education market is particularly relevant. Other countries have witnessed a significant increase in the number of private schools that train nurses at the technical and undergraduate level. Private training builds on business logic with two strands, namely, one of low and another of high quality, and the former is the most prevalent. Mexico follows this pattern, which has also been observed in countries such as Brazil and Colombia³3 Nigenda G, Ruíz J, editores. Formación, empleo y regulación de los recursos humanos para la salud. Bases para su planeación. Cuernavaca Morelos: Instituto Nacional de Salud Pública; 2010..

The deterioration of the nursing labor market is also documented. Underemployment and unemployment rates were reported among Mexican nurses who graduated from universities¹1 Nigenda G, Ruiz JA, Rosales Y, Bejarano R. Enfermeras con licenciatura en México: estimación de los niveles de deserción escolar y desperdicio laboral. Salud Publica Mex 2006; 48(1):22-29. despite nursing staff indicators by population in the country showing the need to train more nurses. These two market phenomena denoted the clear need for state intervention to increase the demand for this personnel by health institutions. Job insecurity for nursing graduates is a market phenomenon that has already been reported in countries such as Brazil and many sub-Saharan African countries⁴4 Melo CMM, Carvalho C, Silva A, Leal J, Santos T, Santos H. Força de trabalho da enfermeira em serviços estaduais com gestão direta: Revelando a precarização. Esc Anna Nery [periódico na Internet]. 2016 [acessado 2019 Jul 2]; 20(3):e20160067. Disponible en: http://dx.doi.org/10.5935/1414-8145.20160067
http://dx.doi.org/10.5935/1414-8145.2016... . In Mexico, it has not been analyzed for nursing, despite some conditions that seemed to be promoting it. Examples of the trend include higher levels of temporary contracts and outsourcing of labor relationships.

On the other hand, it is crucial to consider that Mexican nursing is undergoing a process of professionalization⁵5 Squires AP. A case study of the professionalization of Mexican nursing: 1980 to 2005 [tese]. United States: UMI Microform. Universidad de Yale; 2007. through which it seeks to increase its training years to acquire more specific knowledge about the population's health care and try to establish a monopoly of practice⁶6 Arakaki J. Significados y concepciones de la Enfermería: el punto de vista de estudiantes de la carrera de la Universidad Nacional de Lanús, 2008-2010. Salud Colectiva 2013; 9(2):151-167..

Professional regulation can be understood, in general, as a “dynamic framework within which professional standards can be identified to serve public protection. Regulatory systems must be focused, flexible, and enabling, ensuring that standards are clear, visible, and attainable”⁷7 Organizacíon Mundial de la Salud (OMS). Nursing and midwifery: A Guide to Professional Regulation [Internet]. 2002 [acessado 2018 Jun 2]. Disponible en: https://bit.ly/2JPZeUB
https://bit.ly/2JPZeUB... .

In this paper, the development of nursing regulations in Mexico is contextualized from the existence of factors such as health reforms, demographic and epidemiological changes, new care modalities, as well as the exercise of labor rights⁸8 Mesa C. Las reformas de salud en América Latina y el Caribe: su impacto en los principios de la seguridade social. Comisión Económica para América Latina y el Caribe. Santiago de Chile: CEPAL; 2005..

The professional regulation structure model

The participation of professionals in the production of health services can be studied through the regulation model proposed by Moran & Wood⁹9 Moran M, Wood B. States, Regulation and the Medical Profession. Buckingham: Open University Press; 1993., defined as “the mechanism used to establish the characteristics of the practice and the required technical standards.” This model includes four dimensions: 1) market entry mechanisms; 2) professional competence control; 3) labor market structure; and 4) payment mechanisms¹⁰10 Nigenda G, Machado MH. Modelos de regulación profesional de los médicos en América Latina: elementos teóricos para su análisis. Cad Saude Publica 1997; 13(4):685-692..

For nursing, the market entry mechanism refers to the conditions required to practice. The objective is to obtain a professional certificate or license after complying with the schooling requirements that accredit the bearer as an ideal person to exercise said position.

The regulation of competency is related to functions shared between occupational groups in the health field or with roles not clearly established or recently created, and that may be subject to duplication among health personnel. This regulation implies the “closure”¹¹11 Sommer-Harrits G. Professional Closure Beyond State Authorization. Professions & Professionalism [periódico na Internet]. 2014 [acessado 2018 Nov 12]: 4(1):1-17. Disponible en: http://dx.doi.org/10.7577/pp.567.
http://dx.doi.org/10.7577/pp.567... that members of a profession carry out to avoid or limit the participation of other groups in the activities defined by the profession as their area of influence.

The structure of the labor market is related to how professional groups are inserted into the labor market. In the vast majority of countries, the most common way in which nurses are linked to the labor market is through public health institutions and with salary mechanisms⁹9 Moran M, Wood B. States, Regulation and the Medical Profession. Buckingham: Open University Press; 1993.. The development of independent exercise and the production of private services, outside the institutional environment, are still scarce.

This work aims to analyze the regulatory structure of Mexican nursing through regulations and the stakeholders involved.

Methods

We used the “case study” method as the study's design¹²12 Yin RK. Case Study Research: Design and Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994.. The presentation of results derives from the use of qualitative data complemented with quantitative data. This study was conducted in three simultaneous phases described below.

The first phase consisted of a review of documents that included: news, laws, standards, methodological, and legal tools about the regulation of nursing practice in Mexico. Documents published between 2005 and 2018 that contained information about the regulations, as mentioned above, were included.

The second phase included secondary data from the National Survey of Occupation and Employment (ENOE, 2018) and the Administrative Information System of Human Resources in Nursing (SIARHE, 2018). This information provided a quantitative context of the study phenomenon. The ENOE has a nationally representative probabilistic design, is applied by the National Institute of Statistics and Geography (INEGI)¹³13 Instituto Nacional de Estadística y Geografia (INEGI) [página na Internet]. [acessado 2019 Maio 12]. Disponible en: https://bit.ly/2SgSCQh
https://bit.ly/2SgSCQh... , and is available on its website (https://www.inegi.org.mx/programas/enoe/15ymas/). Data obtained from SIARHE derived from a non-probabilistic survey conducted by the Ministry of Health annually to collect data on the employment situation of nursing staff in the country, which is available at: http://www.salud.gob.mx/unidades/cie/siarhe/.

In the third phase, interviews were conducted (between May 2018 and February 2019) with nurses who were currently working in government decision-making positions with planning and management of human resources functions, both in the health sector and in the education sector; also, nurses were interviewed who worked in clinical, community, educational, research and administrative roles, and had at least five years of work experience. All worked in public institutions.

Eighteen interviews (13 women and 5 men) were conducted in Mexico City. All participants gave their consent¹⁴14 Taylor S, Bogdan R. Introducción a los métodos cualitativos de Investigación. Barcelona: Paidós Básica; 1987.. Given the level of information and experience, as well as their perspective on the institutional structure, their opinions reflected a phenomenon occurring on a national scale.

The access to the informants was made through professional networks¹⁵15 Rodríguez G, Gil J, García E. Metodología de la Investigación Cualitativa. 2ª ed. Granada (España): Ediciones Aljibe; 1996. and the selection of the subjects through a “sampling of maximum variation”, which in this case corresponded to the health personnel and nurses who complied with the characteristics described above. The interviews were analyzed using content analysis¹⁶16 Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005; 15(9): 1277-1288., preserving the identity of the participants by assigning pseudonyms to each interview.

This work is part of a broader research on nursing professionalization in Mexico, which was evaluated by the Ethics Committee of the National Institute of Public Health of Mexico, before the collection of primary data, which validates compliance with the ethical aspects thereof.

Results

The results of the four dimensions proposed by Moran and Wood are arranged in three sections: stakeholders participating in the process, existing regulations, or processes defined by the corresponding authority and results of the regulatory exercise in the 2005-2018 period.

Table 1 shows the documents oriented towards the regulation of nursing in Mexico. These documents are the basis for the analysis of the stakeholders participating in the regulation, processes, and results of each realm.

Market entry mechanisms

The stakeholders of this regulatory process are: a) the Congress of the Republic, establishing the achievement of a professional degree as a requirement; b) Higher Education Institutions (HEI), when issuing said title; and c) the General Directorate of Professions (DGP) of the Public Education Secretariat, when issuing a professional ID to the new graduates, equivalent to a practice license.

The DGP issues the practice license. However, the intervention of the State to enforce the regulation is minimal since it is common for undergraduate students to be hired into mainly private health units. Public institutions do request a practice license to hire a nurse, even part-time.

A new strategy of re-entering a specialized market is through the certification of professionals. This consists of the verification of theoretical knowledge in a specific area, which makes them suitable professionals to perform in the field of interest as per the evaluating institutions, which is equivalent to re-entering a more specialized market niche. Nurses organized in schools authorized by the State to carry out this function participate in this process.

Professional competence control

The main stakeholders in this process are the Permanent Nursing Commission (CPE), who participates in the presentation of draft standards and in their follow-up, as well as the Congress of the Republic, responsible for reviewing and approving the proposed standards.

In this realm, nursing regulation is scarce and oriented to institutionalized care exercise. The Official Mexican Standards (NOM) establish nursing's field of action in the national territory. We also find draft standards (PROY-NOM) that aim to create independent exercise spaces, which have not yet been approved and are still pending review.

A greater emphasis on internal competence criteria (between different training levels) is observed through the approved standards. The NOM-019¹⁷17 Norma Oficial Mexicana NOM-019-SSA3-2013. Para la práctica de la enfermería en el Sistema Nacional de Salud. Diario Oficial de la Federación 2013; 2 ago. establishes differentiated functions for each training level, favoring staff of higher academic level. Concerning external competence criteria, the NOM-007¹⁸18 Norma Oficial Mexicana NOM-007-SSA2-2016. Para la atención de la mujer durante el embarazo, parto y puerperio y de la persona recién nacida. Diario Oficial de la Federación 2016; 7 abr. and Art. 28 Bis of the General Law of Health (LGS)¹⁹19 Acuerdo por el que se emiten lineamientos que contienen el procedimiento y los criterios a los que deberán sujetarse los licenciados en Enfermería, así como los pasantes en servicio social de las carreras referidas en los numerales 1 al 5, del artículo 28 Bis, de la Ley General de Salud, para la prescripción de medicamentos. Diario Oficial de la Federación 2017; 8 mar. stand out, both of which establish the participation of nurses with a bachelor's degree, matching their responsibility and support of their activities with that of other health professionals.

In practice, the area that nurses have established as their natural space is that of “care”, which is hugely indefinite as it includes promotion, prevention, personal care, rehabilitation, and palliative actions. Several occupational groups compete with nursing the implementation of actions, particularly doctors. Currently, a specific field where nursing has gained ground to establish its practice model is in the low-risk delivery care.

Labor market structure

The main stakeholders in this field are the public and private health institutions that define their nurses' requirements as per their internal guidelines. The leading employers of nurses are the Ministry of Health (SSA) and the Mexican Social Security Institute (IMSS). In these institutions, the unions of the institutions play an essential role in negotiating the terms of recruiting nurses as per collective agreements. However, the jobs protected by the union have been significantly reduced, and the new forms of recruitment are temporary and do not include the rights defined by Mexican labor law. Private institutions have increased their presence in the last 20 years, and are an increasingly important source of demand but with more flexible working conditions compared to public institutions, particularly concerning the existence of contracts with no defined term.

There is no general market regulatory process to establish a balance between the supply and demand of nurses, so each institution establishes its strategies for the recruitment of nurses by level of training. However, some labor regulations establish how contracts must be offered and the benefits to which workers are entitled²⁰20 México. Ley Federal del Trabajo, de 12 de junio de 2015. Diario Oficial de la Federación 2015; 12 jun..

Data from the Ministry of Health reveal that, between 2006 and 2018, nurses licensed in the labor market have risen from 16.6% of the total nurses to stand at 37.1%, with the implicit reduction in the representation of nursing technicians and assistants. However, in 2018, nursing technicians accounted for 47.6% of the market and were still a majority²¹21 Secretaría de Salud (SSA). Estado de la enfermería en México 2018 [Internet]. México: OPS, OMS; 2018. [acessado 2019 Maio 12]. Disponible en: https://bit.ly/2UDYesB
https://bit.ly/2UDYesB... . The increasing trend of university nurses is also confirmed with data from the ENOE²²22 Aristizabal P, Nigenda G, Servan-Mori E. The precarization of the Mexican nursing labour market: A repeated cross-sectional analysis for the period 2005-2018. Human Resources for Health. In press..

On the other hand, the type of contract varies across institutions. In the Health Secretariat and the IMSS subsidized regime (IMSS-Prospera), temporary nurses with temporary contracts represent 36% and 35% of the workforce, respectively. This recruitment type in private institutions reached 21% of the total number of nurses hired. The social security institutions (IMSS and ISSSTE) to date have managed to keep their workers' cadre with permanent contracts and replace the deceased and retired with new staff occupying those positions.

Payment mechanism

Nurses work predominantly in institutions, so the most common way to receive income is through salaries. According to ENOE data, in 2016, 75% of nurses with employment were salaried, 6.4% declared themselves as the owner of a company, and 15.3% self-employed.

Salaries are established by the entity that hires the services, commonly following national policies and the approval of annual budgets by the National Congress. The Ministry of Finance and Public Credit approves the labor codes and salaries associated with them, for public health institutions. Each institution establishes its salary categories from these codes. As noted, most of the nurses in the country work for public institutions, and the two institutions that incorporate the majority of nurses at their different levels are the Health Secretariat (42%) and the Mexican Social Security Institute (34%). Both are powerful stakeholders in the negotiation of wages and payment methods. Salaries are negotiated periodically with the unions of the institutions.

Both the SSA and the IMSS have different ways of categorizing nursing levels, but in general, are divided into assistant, general, and specialist. Also, we have positions of command, denominated positions of trust, that are not included in the union negotiations, as is the case of temporary contracts, which arrive at 36% of all jobs in the SSA, and less than 1% in the IMSS. Each level is assigned a code that, in turn, contains the job description and salary. The salary structure is complex since the fixed amount that a worker receives biweekly consists of a set of items as per productivity, labor risk, and geographical location, among others. In the SSA, the salary consists of three items: a) monthly base salary, b) gross monthly allowance, and c) assistance for monthly gross update expenses. The monthly base salary is used to calculate the worker's pension upon retirement. The rest of the salary items are not used to establish the value of the pension, but if taxes are deducted. The value of items b) and c) can reach a proportion of 50%, depending on the occupational category.

Discussion

The results shown suggest that the nursing regulation model or mechanism in Mexico is in a development process and that its results are still to be determined. The development of a regulatory nursing structure has accelerated in the last two decades as a result of global changes in the training of health professionals and the acquisition of demonstrable skills, as well as in the reform of health systems that promote management of resources as per criteria such as cost control and increased productivity²³23 Organización Panamericana de la Salud (OPS). Regulación de la Enfermería en América Latina. Washington, D. C: OPS,OMS; 2011. (Serie Recursos Humanos para la Salud No 56)..

These nursing regulation adjustments are a concern in various countries. For example, in Australia, the recent expansion of positions and roles of nurses in the health system requires an update of the regulation to generate an articulated order among this whole range of functions²⁴24 Duffield CM, Gardner G, Chang A, Fry M, Stasa H. National regulation in Australia: A time for standardization in roles and titles. Collegian 2011; 18(2):45-49.. The study published by Robinson and Griffiths²⁵25 Robinson S, Griffiths P, National Nursing Research Unit. Nursing education and regulation: international profiles and perspectives. London: Kings College London; 2007. on the regulation of nursing in OECD countries emphasizes educational aspects since, until recently, the training of nurses was transferred to universities; however, some countries still maintain it in the hospitals. Also, mobility between the European Union (EU) countries has demanded strategies for harmonizing training curricula to ensure employment opportunities in member countries.

Four dimensions were used to study Mexican nursing regulation, which together underpin the regulatory model proposed by Moran and Wood⁹9 Moran M, Wood B. States, Regulation and the Medical Profession. Buckingham: Open University Press; 1993.. Each shows varying advancements compared to the general model. These differences are established both in the participation of stakeholders and the development of the processes, but particularly in the endpoints.

The first dimension of market entry reflects that regulatory mechanisms are established and sufficiently specific. While the State grants a license, one can observe its incapacity to ensure graduates' market entry as licensed nurses. This control is also not exercised by professional representation groups, which favors the breach of current regulations and opens up spaces of vulnerability, which are exploited by the employing institutions. There are at least two ways of entering the market that do not comply with the regulations: private institutions temporarily hire active students and people with incomplete nursing training to fulfill the functions of a licensed nurse, and the incorporation of students (social service) who completed university credits but have not received a degree or license, in order to offer them a practice space for one year. These students perform activities that are frequently equivalent to those of a registered nurse.

As noted in the results section, the nursing functions are established around care, which includes a wide range of different technical level actions. Since care is such a broad field of activity, various occupational groups compete with the nurse²⁶26 Cook LB, Peden A. Finding a Focus for Nursing. The Caring Concept. ANS Adv Nurs Sci 2017; 40(1):12-23.. Together with the scarce regulation in this realm, this feature makes it a complicated process to establish norms that define a clear monopoly of practice and allow nurses to protect themselves against their competitors. Behind this phenomenon is the fact that nursing has different levels of training; therefore, competences differ by level of training. Training at the technical level implies the development of essential competences, while that at the university level, it includes, besides clinical competences, more complex skills such as health services management and research²⁷27 Castañeda-Godínez MC, Pérez-Loredo Díaz L, Pérez-Cabrera I, Müggenburg-Rodríguez Vigil MC. Formación professional de enfermería durante la primera mitad del Siglo XX en la UNAM. Revista Enfermería Universitaria ENEO-UNAM 2010; 7(n. esp.):25-32.. However, delivery of nursing care is a field of practice where progress has been made in the control of competences. As of the approval of the modified version of the NOM-007-SSA2 standard of 2016, respected delivery models where obstetric nurses have gained autonomy, control over their practice, and specificity in their execution²⁸28 Díaz-García S, Zavala-Suárez E, Ramírez-Hernández C. Evaluación de las competencias en enfermeira como reflejo de calidad y seguridad en la mujer embarazada. CONAMED 2013; 18(13):104-110. have been implemented. Other practice control areas are more specific, such as home care and wound treatment.

The nursing labor market shows differences associated with the segmentation of the Mexican health system. Three large segments are noted, namely, Social Security, the Health Secretariat, and private institutions. Social Security has oriented its nursing staff requirements to recruiting technicians, despite the increasingly full availability of licensed nurses. The private sector also preferably employs nursing technicians to place them in hospital units²¹21 Secretaría de Salud (SSA). Estado de la enfermería en México 2018 [Internet]. México: OPS, OMS; 2018. [acessado 2019 Maio 12]. Disponible en: https://bit.ly/2UDYesB
https://bit.ly/2UDYesB... . Instead, the Ministry of Health has chosen to recruit licensed nurses as they are available in the market. One-third of these nurses are located in first level care units. However, employment conditions between nurses in the private sector and those in the public sector have deteriorated significantly in the last decade through the phenomenon of insecurity²⁹29 Progianti JM, Moreira NJMP, Prata JA, Vieira MLC, Almeida TA, Vargens OMC. Precarização do trabalho da enfermeira obstétrica. Rev Enfermagem UERJ [periódico na Internet]. 2018 [acessado 2019 mar 13]; 26:e33846. Disponible en: https://doi.org/10.12957/reuerj.2018.33846
https://doi.org/10.12957/reuerj.2018.338... . The regulation of these phenomena in their most essential aspects is incumbent on the health institutions and their union structures. Although the current legislation – approved by the Health Secretariat as responsible for the system's governance – establishes differences between the training levels, the competences, and functions of each level, the institutions carry out the recruitment based on their priorities. The proper allocation of nursing levels in the health services structure is not a strictly national matter. Some differences are found among OECD countries between nations that train nurses in universities and those that do so in hospitals with technical levels³⁰30 Organisation for Economic Co-operation and Development (OCDE). Regions at a Glance. Paris: OECD; 2007..

The original Moran and Wood⁹9 Moran M, Wood B. States, Regulation and the Medical Profession. Buckingham: Open University Press; 1993. approach designed for the study on the regulation of doctors emphasizes the different payment mechanisms that exist for this occupational group. However, in Mexico, as in many other countries, nurses are salaried or hourly wage earners in public institutions. Therefore, other payment mechanisms such as fees, capitation, or payment for performance are scarce in these institutions. For the case study, differences in salary structures between institutions were identified despite this homogeneity. The salary differences for nurses working 40 hours a week in public institutions are not significant. However, important discrepancies are observed between permanent and temporary workers. Permanent workers receive more generous salaries, but, over time, have been restructured following a rationale that protects the institution from paying a pension for the total income at the end of the worker's labor cycle³¹31 De Lara-Landa M. Derecho al trabajo y trabajo precário en México. Rev Investigación en Derecho, Criminología y Consultoría Jurídica 2017; 11(22):165-190.. In the Health Secretariat, the availability of permanent positions was drastically reduced at the beginning of the century, and the incorporation of nurses occurred through temporary contracts. In these contracts, workers are not entitled to a pension at the end of their work cycle and, therefore, the salary is compacted without differentiating between base salary and compensation. This rationale in the salary structure is the same as that used in the private sector³²32 Sánchez-Ildefonso LA. Análisis de puestos y sueldos de personal de mando en la Administración Pública Federal 2018. Encrucijada 2018; 30:55-76.. Nurses' struggle for the value of wages and pensions is not exclusive to Mexico. In England, for example, in 2014 a 1% increase was suggested to the Ministry of Health to offset the loss of the salary value of nurses, which was rejected by the government at that time but applied until 2016 for all staff³³33 Department of Health and Social Care. NHS staff to receive 1% pay rise. Government sets out the pay awards for all NHS staff [reportagem na Internet]. 2016 [acessado 2019 Maio 12]. Disponible en: https://bit.ly/1U1hCZM
https://bit.ly/1U1hCZM... . Another aspect that the English government has emphasized has been the reduction of outsourced contracts for cost control³⁴34 BBC News. NHS England cap on agency payments comes into effect [reportagem na Internet]. 2015 [acessado 2019 Jun 12]. Disponible en: https://bbc.in/30mOUZN.
https://bbc.in/30mOUZN... .

Self-regulation is a sign of the status of a profession. From the perspective of the sociology of the professions, the professions seek to ensure that their members acquire the skills and competences of their field of knowledge at the highest level, for which they must receive formal recognition at the end of the training. The regulation also ensures that skills acquired in training are put into play in the labor market, to build monopolies of practice by excluding individuals who are unable to show that they have the corresponding training³⁵35 Freidson E. La teoría de las profesiones. Estado del arte. Perfiles Educ 2001; 23(93):28-43.. Other realms in the professions are not subject to regulation, among which are the development of a professional ideology or social prestige. Therefore, the regulation interferes with the development of specific realms of professionalization. A key aspect in professionalization is that members of the occupational group join to become a political stakeholder who participates – and ideally controls – the definition of standards, processes, and results of the regulation. In Mexico, the nursing regulation process has been built around state policy with the growing participation of nursing groups. The results point to the development of a state control model with the participation of nursing in primary aspects for the next years.

Conclusions

The State is the dominant stakeholder in the regulatory apparatus of nursing in Mexico. However, it has recently encouraged the participation of other players, including nursing representatives. The State maintains under its control licensing as a market entry mechanism. It also has a significant influence on the market since the regulatory processes are dominated by public institutions in which the State defines recruitment policies and payment mechanisms. As the main actor, the State has the responsibility of generating mechanisms between supply and demand that are compatible and balanced. On the other hand, nursing must develop strategies to increase its participation both in strengthening the legislation and monitoring its compliance thereof.

References

Publication Dates

History