FINAL REPORT FROM THE FORUM ON NURSING PRACTICE REGULATION IN THE REGION OF THE AMERICAS

There are nearly 7 million nursing professionals in the Region of the Americas, representing more than 56% of human health resources. The regulation of professional practices promotes and protects professional integrity, ensuring professionals are competent and well qualified. The Forum on Nursing Practice Regulation in the Region of the Americas aimed to present the regulatory frameworks for the professional practice of nursing; discuss strategic actions to support professional regulatory bodies; analyze requirements for licensing and renovating licenses; and share successful experiences in nursing regulation. The Forum counted on the participation of 83 guests in-person, with representatives from 17 countries from Latin America and the Caribbean. The COFENplay platform registered the participation of 6,906 spectators. The debates in the event led to the proposal of the following recommendations: promote a national discussion with key-actors, including the Ministries of Health, Education, and Work and Employment, to advance regulation in the countries; recommend an intersectoral articulation with the topic of Human Health Resource regulation; generate a common base for the identification of information on regulation; and broaden the research about these topics, as well as the ability to generate and analyze data.


INTRODUCTION
the COViD-19 pandemic generated serious effects in the Region of the Americas, especially regarding human resources in health (HRH).However, it also taught us certain lessons that should not be forgotten.in 2017, the 29th Pan American Sanitary Conference approved a Resolution which determined the human resources strategy for universal health access and coverage. (1)this strategy was followed, in 2018, by a specific Action Plan, which determined that, in addition to other indicators to be reached from 2020 to 2023 (2) , countries have formal regulatory frameworks that determine the functions of health professions according to the needs of health care models.the first strategic line of action is strongly related with the topic of this Forum, which aims to strengthen and consolidate the governance and leadership of human resources in health.More than half the professionals in the field of health are nurses and this is a profession that has clearly shown its relevance throughout history.
in the Region of the Americas, there are nearly 7 million nursing workers, representing more than 56% of the health personnel. (3)in addition to the important role they have in health services, their activities can be improved with adequate education, regulation, and interprofessional work, to promote universal access and reach Sustainable Development Goals (SDGs). (3)However, one of the key actions to advance nursing in the region is strengthening its regulatory frameworks.
the Pan American Health Organization (PAHO), through a document called "the Strategic importance of National investment in Nursing Professionals in the Region of the Americas", and according with "the WHO Global Strategic Directions for Nursing and Midwifery (2021-2025)", called attention to the importance of investing on education, employment, leadership, and the practice of nursing. (3)e regulation of professional practice promotes and protects professional integrity.it is a mechanism to guarantee competent and well-qualified professionals.legislation and regulations must be reviewed to optimize certain aspects of professional practice, considering factors such as competences, professional roles, optimization of the work force, migration, recruitment, retention, work conditions (such as personal safety and job security), and professional nursing rights (such as decent workplaces and work hours, safety at the workplace, and attractive pay).
Nursing throughout the Region of the Americas tends to follow the same challenges, which were especially intensified after the COViD-19 pandemic, which shed a light on the adversities these workers deal with in the front lines.the regulation of nursing work is an important topic for the advance of the profession.At this moment, after the pandemic, the struggle to guarantee the recognition and appreciation of the profession has grown.Due to the increasingly fast development of globalization processes, a discussion about the regulatory frameworks of the profession has become essential.
the COViD-19 pandemic confirmed that working to guarantee primary care-based universal coverage and access to health is the pillar of a resilient health system, able to provide efficient responses to crises while also attending to basic needs, thus reorganizing and transforming itself as conditions require. (5)Health human resources are the pillars of a health system.However, one must improve the planning and management of resources by encouraging retention policies that contemplate dignified work conditions, giving support to the needs of health workers.this includes mental health services.in the Region of the Americas, all countries regulate nursing professions through a regulatory body.the United States, Canada, and most countries in the Caribbean require one to go through competence tests to obtain their first license.54.3% of countries also require a periodical professional license renovation. in the United States and Canada, and in 53% of countries in the English Caribbean, continuing education is mandatory to renovate one's license. in the United States and Canada, one must also register their number of work hours. (4)ofessional practice regulation is essential to perfect the structure of health systems and strengthen the work of nursing teams.Health cannot be promoted with no investment in human resources, and nursing workers must be provided with education to guarantee the quality of care and ensure that large portions of the population are cared for, with humane, evidence-based practices.it is essential to revise the legislation and regulations to optimize professional practice, considering competences, responsibilities, work force, migration, and dignified work conditions, in order to ensure the safety of nursing workers and patients, in addition to increasing the efficiency and problem-solving capability of health services.
Regulating is more than simply considering the scope of practice according to a specific set of competences; it also involves articulating this topic with other aspects that are transversely associated with the professional exercise of nurses, associating them with working conditions, work relations, work processes, and employment bonds.Nursing, as a transversal profession, interfaces with many of the SDGs, meaning that the nursing personnel is strategic to reach these goals.there are documents created to boost the regulation of the nursing field.these documents are signed by the three affected parties: employees, employers, and the government.the first of these documents was established in the 111th international labour Conference, held by the international labour Organization (ilO).it is a worldwide call to action seeking a people-focused recovery from the crisis caused by COViD-19 -one that is inclusive, sustainable, and resilient.the document "Securing decent work for nursing personnel and domestic workers, key actors in the care economy", produced by ilO, chose nursing workers and domestic workers, specifically, due to their chain of care (6) .it was developed based on questionnaires sent to 115 countries, and received responses from governments, worker organizations, and employers.However, only 41 of the member states ratified its contents.A ratification is a guarantee that the document will become part of the regulatory body of the State.the relationship between bad work conditions in the nursing personnel and the persistent scarcity of personnel is complex.the most concerning issues are: wages; work journeys (often long and involving shifts at undesirable hours); rest time and vacations; inadequate protection of health and work safety; insufficient social security coverage; lack of educational opportunities, work organization, and opportunities to further one's career; little participation of the nursing team in the making of decisions concerning their own work conditions.the gender issue is also important, not only due to the feminization of work, but also due to episodes of violence against women and wage gaps.Social security and protection to maternity are important elements, and the lack of protection to maternity directly affects women; however, caring for family and children should not be their exclusive responsibility.
the ilO recently made available a document on the value of essential work that included eight professional groups, with health workers representing 52% of total essential work.A good practice would be having an observatory of safety and health at work, since it would allow for the quick identification of several pieces of information.
For example, in Brazil, the nursing technician is the type of worker who suffers the most work accidents. (7)

REGULATION OF PROFESSIONAL HEALTH PRACTICES
A study of regulatory frameworks in Australia, Canada, the USA, and the United Kingdom led to a report that highlights the jurisdictional differences in the way these countries regulate the scope of the practice of different health professions of public interest. (8)ere are several challenges in this regard, including the lack of a common regulatory terminology, different political environments, several institutional arrangements, and task distribution, in addition to different legislations that allow the emergence of such issues.
Fundamentally, the goal of these regulatory frameworks is to ensure that the population will receive quality health care.Regulations must clearly define the scope of each professional practice, while being flexible enough to allow for innovation, transparent, and publicly responsible.in the USA, each state is responsible for creating its own professional regulation.the scope of practices is not significantly different from one state to another, but, in the case of head nurses, there are substantial divergences.in 2020, the states recognized the need of increasing health personnel size to deal with the pandemic.Many states launched more flexible regulatory executive orders regarding the scope of the practices, albeit within a limited time frame.
As time passed, it became clear that it was necessary to facilitate the licensing of health workers, allowing them to use telehealth services.Professionals and services could use distance care, and even retired or inactive workers could contribute.When the pandemic started to decline, it had some important impacts on the workforce.the magnitude of the lack of professionals increased, as it did in other sectors.While attempts were made to seek health workers, other employers also sought professionals in their respective fields, but with more interesting conditions for the job market, showing the need to facilitate the professional life of the nurse.it is also important to create spaces for the discussion and construction of more solid and resilient systems in the Region.the current challenge to nursing is the construction of a system of care for persons in a world with such technological innovations.
A report from The Lancet (9) showed that public and insurance expenses are growing exponentially.there is a set of studies on inadequate expenses and waste in health, due to mistaken clinical decisions made as a result of complex events.Nursing has to contribute for the construction of models of efficiency in health that are sustainable in the long run.

REGULATION IN NURSING: HOW TO APPLY, PRACTICE, AND EVALUATE
Regulations must contribute to protecting the population, guaranteeing the quality of care to the patient, and to establishing, promoting, and reiterating the standards of its practice.in terms of socioeconomic wellbeing, one must guarantee the interests of nursing workers, so their patients can be provided with the best attention possible.
Our considerations must go beyond respect.they must strive towards fair payment and bear in mind the perspectives of both civil society and professionals, always keeping in mind the valuable contributions of nurses.
Broadly, regulations are government mechanisms to control an activity, service, or behavior.
One must reflect on the recent emergency we experienced, which required exceptions regarding the scope of nursing practice and showed that nurses have the knowledge and judgment to carry out the necessary activities.
We must ask whether this took place only during the pandemic, if it will only happen again in a future sanitary crisis, or if it will be adopted as a "new normal".
Education and regulation continue to evolve, and modernization is necessary for care to be more accessible, better, increasingly empowering these workers.
the World Health Organization (WHO) published the State of the World's Nursing Report in 2020 (11) , recommending that regulations to promote international mobility of nurses should be improved by equalizing the requirements for the practice of the profession, educational standards in nursing, and requirements of continued education.in this regard, the perspective of health systems must be considered, including Primary Health Care, public health, long-term care, and hospitals, since each is subject to its own laws and regulations.these levels, though different, are interrelated.there has been a triple collaboration between the WHO, the international Council of Nurses (iCN), and the international Confederation of Midwives (iCM), and, as a result, it is really possible to deliberate on what should to be achieved and improved in the context of local, national, and global work forces and regulations.the document "Global strategic directions for nursing and midwifery 2021-2025" (12) , by the WHO, shows four political priorities: education, jobs, leadership, and service delivery.it is also essential to examine the demands of the system and the population.
Educational levels in nursing and obstetrics must be in line with the functions of academic and health systems.
Moreover, health education programs must be based on competences that attend to the health needs of the population, in addition to guaranteeing that the academic staff is adequately trained in the best new pedagogical methods and technologies.
From the perspective of the leadership, the proportion of nurses and midwives in academic and senior health roles should be increased, and there should be investments in Regarding work, we estimate that, currently, many nurses are unemployed and have to compete for work posts.
Wages, competition between nurses, and the possibility of service delivery roles must be taken into account, considering the policies and the regulatory services that may or may not allow this integration.therefore, we must plan and predict the future of the nursing and midwife workforce from the perspective of the health work market; ensure an adequate search (for employment), regarding the delivery of health services for primary care and other health priorities of the population; and attract, recruit, and retain midwives and nurses where they are needed the most.
For service delivery, systems of professional regulation must be reviewed, and regulatory agents must receive further education when necessary; workplaces must also be adapted, to allow for midwives and nurses to contribute as much as they can to provide services in interdisciplinary health teams.the implementation of regulations must be an open, transparent, and dynamic process, valuing the participation and representation of the population, with government oversight.it can take place from two perspectives.Public safety is essential for Relational Regulation, but collaborative relationships and networks are the true responsible for advancing discussions, and the regulatory approach is based on principles, as opposed to rules.the culture of "Right touch Regulations", which involves evidence-based risk assessments, is a "fair culture", a learning culture, and not a "disciplinary or guilt-based culture"; it uses minimum regulatory overview to reach the desired results, taking advantage of mistakes as opportunities for learning, as opposed to moments to attribute guilt.the scope of the practice is not a form of control, but represents the roles, functions, and responsibilities that professionals are authorized to perform.therefore, its aim is not to restrict -after all, the profession of nursing saw workers from the emergency department who, now, can provide distance care. in Canada, for example, there are decrees that allow psychiatric nursing workers to prescribe medication.Nurses have four pillars that work together, because if they did not, that would represent a challenge in itself.these pillars are related with practice, regulatory governance, defense mechanisms, and the improvement of education, and are: nursing professors; regulators, that is, councils or regulatory bodies; government, for example, the director of nursing and obstetrics at the government, the minister, and nursing leaders; and professional associations, such as leaderships and syndicates.
Professional support is essential, as well as the role of global nursing leaders and nursing directors, to harmonize the workforce.there is an ongoing regulatory project in Canada that aims to plan and implement a new regulatory model of the "Nurse Practitioner" in Canada as a whole, searching to reduce unnecessary barriers and promote workforce mobility throughout the country.Some lessons about regulations learned from the COViD-19 pandemic: clarity in parameters and reduction of barriers to the practice; need for work in collaboration with the interested parties; impact on the workforce due to the responses of regulators to the pandemic; support to health systems and workers; and evaluation of the impact of regulation on the capacity of the workforce and safety.

Key takeaways:
1) Government investment is needed to support regulation.
2) there must be a nation-wide involvement among interested parties.
3) Competences must be developed in accordance with practice.
4) Health systems and research capabilities must be developed to promote educational policies and health regulations.

Integral de Evaluación de Residencias del Equipo de
Salud (SiER) articulates actions to evaluate and standardize education. (14)e law of technical Professional Education (15) regulates the formation of technicians, determines their professional profile and all their functions, and licenses them to exercise their work throughout the national territory, as long as the career is approved by the National Ministry of Education.Professional exercise laws are jurisdictional, and there is a federal law whose scope is the city of Buenos Aires and all federal territories.there are several legislative models of professional exercise, but, in general, each is about one health profession. the ertification of specialties is regulated by laws of pro- the professional exercise of nursing is regulated by National law 24.004.(16) there are 14 other specific jurisdictional laws.the Ministry of Health recognizes six specialties on a federal level 199/11: (17) adult health nursing; older adult health nursing; mother-child and adolescent nursing; psychiatric and mental health nursing; nursing for neonate, pediatric, and adult critical patients; and nursing for palliative care. in some careers, nursing has its own regimens.in tierra del Fuego, for example, or in careers that consider it to be part of the administrative regimen. in general, nursing has no disciplinary union, but negotiates through the health syndicate (FAtSA), which represents non-medical workers.there is wage dispersion along the subsectors and levels.
Recently, the Coordination of Nursing was created within the Nation Ministry of Health, and the Permanent National Assistant Commission for Nursing was renovated, opening new spaces for nursing in health policies.
there was also a process of nursing professionalization, with scholarships for technical and university education.Nursing auxiliary courses are not valid in the nation as a whole, but Bill 2346-D-2021 aims to favor the qualified formation of nurses, increase the number of professionals, and promote their development in the national territory. (18)is Bill, named "Promoting the Formation of Nursing Development" (2346-D-2021)" (18) , prescribes the enhance- Furthermore, reference frameworks must be adapted, and higher education for technicians and nurses must be standardized, as do specializations.Finally, specializations in the field of nursing must be developed; the profile of specialists and their specific competences must be determined; and the new law to promote nursing must be sanctioned.

Brazil
in Brazil, health is a duty of the state and a right of every citizen.Any regulation in the country must also guarantee that the population has access to health.Good regulation provides concrete guarantees for a certain right.the right to health is part of a public and universal health system, provided to 220 million people.Any regulation has to bring benefits to the public system.Of course, the private system must be considered, but the public system must be prioritized.
the SUS brings together public health services and actions provided by the Union, the states (27), and the municipalities (5,570), all of which hire nurses.the SUS proposes a system of universal, free, equal, and integral access to health care.
the Union (the executive branch of federal power) is the highest authority for standardizing (elaborating general norms) and defining national policies in the field of health.Nowadays, in Brazil, there are 14 professions in the field of health that require university education, including nurses, as determined by Resolution CNS 287/98. (19)gulation in the field of health is fragmented, involv- in regard to work relations, regulation is more complex, since there are several types of contract, with different regulations for the private job market, public workers, and employees of private companies that outsource services for the SUS.Work relations are regulated by several standards, but also by the Federal Constitution itself. (20)the current model has produced countless regulatory conflicts that affect the organization of the public health system.there are conflicts between the different professional councils; between the councils and the citizens; and between the councils and the ministries of the federal executive branch.
Due to a lack of consensus among these parties, several discussions have taken to judicial courts.
this model of regulatory entities should be reconsidered.Regulation is a strategic topic, essential for professional exercise to be in accordance with the health needs of the population.the corporate regulation of health professions must be integrated with Public Health Policies, especially those of the SUS. the autonomy of Councils is important to qualify and control professional exercise; however, it is also a source of conflicts, market reserves, and corporate interests.the Brazilian Federal Constitution, enacted on October 5, 1988, instituted the SUS and the access to health as a right of all citizens.Nursing is one of the most well-established professions in the country in the field of health, and is regulated by law 7.498, from June 25, 1986 (21) ; by Decree 94.406, from June 8, 1987, (24) ; and by law 2.604/1955. (25)these are the regulatory frameworks of nursing, which not only determine the legal limits of the exercise of nursing in Brazil, but also establishes who can exercise the profession and what are the necessary conditions to do so. in Brazil, nursing is performed by nurses, nursing technicians, and nursing auxiliaries.Regardless of the specific professional activity, the professional must be registered in the Class Council. in 2013, the Federal Nursing Council (COFEN) recognized, through a resolution, the profession of midwife, which became yet another professional category in Brazil, despite there being, as of now, few midwives in the country. (26)e nurse is the only nursing professional that can exercise all activities defined by current legislation.in Brazil, nursing became an official profession in 1950, and ever since it had well-defined regulatory frameworks.there are two laws, a decree, and over 700 resolutions that regulate its professional exercise in Brazil.these legal frameworks guarantee that these professionals will be able to carry out their work autonomously.in Brazil, the Federal Nursing Council (COFEN) and the Regional Nursing Councils Evidence: fact or information available, indicating whether a belief or hypothesis is true or valid.Note: Approaches or ways of life based on native culture are considered to be evidence.
Fair culture: being fair and reasonable, focusing on the identification of factors in the system that contribute for errors, so changes can take place to improve safety.Philosophy: a system of principles to guide practical matters.
Principles: truths or fundamental propositions that function as bases for a system of belief or behavior.
Proportionality: regulators should only intervene when necessary.Solutions should be adapted to present risks and costs should be identified and minimized.
Consistency: rules and standards must be implemented fairly.
Target: regulation should be problem-focused and minimize collateral effects.
Transparency: regulatory institutions should be open and ensure that regulations are simple and friendly.
Responsibility: regulatory institutions must be able to justify their decisions and be subject to public scrutiny.
Agility: regulatory institutions must look forward, being able to predict changes and adapt to deal with them.

Colombia
Colombia has a Policy for the Development of Human talents in Health, which involves the following laws: • law 1164, from 2007: (30) establishes the processes of planning, education, surveillance, and control of the exercise, profession, and development in the field of health by articulating the several actors that intervene in these processes.Graduates must work as social workers for at least one year, after which they receive their professional licenses to work in the field.
Regarding university nursing courses, it was established that 70% of the content of these courses would be unified for the country as a whole while 30% of the workload should be adapted to the needs of each location.there is also a plan for the development of continued education.there are only two categories of workers. in the medium term, the goal is having more nurses than nursing technicians.there will also be obstetric nurses, whose course will last for three years.
Most nursing professionals are women, and their education mostly takes place in capital cities.Migration is a concern, since, last year, 1.100 nurses migrated to more economically developed countries.
A bill has been created to reform the health system of Colombia.this is the perfect moment to review the role of the nursing worker, who is too focused on disease, and not very focused on prevention.these incentive models are pilot projects and will have to be implemented, in addition to necessary adjustments to curriculum and salaries.
Changes in continued education will be implemented and focused on public health.

Costa Rica
Regarding the historical aspect of the regulation of nursing in the country, the first law in this regard is from 1973, regu-

Ecuador
in Ecuador, there are three areas involved in the elaboration of the regulatory framework: Assistance (through the Organic law of Health, (35) the law of Careers in Health, (36) , the Organic law of Public Service, (37) , and the labor Code (38) ); Association (through the law of Professional Exercise (39) ); and Academic (through the Organic law of Higher Education, (40) and the Academic Regime Regulation (41)).these different laws were achieved after 20 years of worker struggle.the Organic law of Health applies to all public servers, while the labor Code applies to all private workers.With regularization, the entire process undergoes continuous improvement.in the academic field, there is a law of higher education (40) enforced by the National Secretariat of Science and technology and by the Higher Education Council.this organism is in charge of professional practices in the country.Since 2015, there has been a process of improvement of higher education designations, thanks to which, from 29 existing courses, 24 were approved, while others, albeit still not approved, are continuously improving.there are 32 nursing courses, 70% in public institutions and 30% in private ones.From 2000 to 2020, there has been an increase in the number of nursing professionals. in Ecuador, only those with nursing and nursing auxiliary graduations are regulated.Graduates from foreign institutions cannot be hired.Furthermore, professionals with technical or technologist formation have no place in the field.Currently, the nursing body is formed by nurses and auxiliaries.in Jamaica, there are seven institutions approved for the education of nurses, three accredited schools for the education of midwives, and three for the education of nursing auxiliaries.the regulation of nursing and midwifery was enacted in 1964 and updated in 1966 and 2005. (46)the Nursing Council of Jamaica has the power to control the education of nurses, midwives, and nursing auxiliaries, ensuring safe and quality attention to the population.Furthermore, the council determines the requirements for candidates to nursing education, obstetric nurses, and nursing auxiliaries, providing education program, exams, and curricula, and allowing the establishment, management, and control of schools, while also regulating the registering of nurses; it also regulates disciplinary action procedures.
Regulations must be updated, considering new developments of education in nursing and midwifery, the increase in the scope of these practices, task delegation among nursing workers, telehealth application, and the advancement of technologies.Other relevant aspects include the effects of the COViD-19 pandemic, the inclusion of other categories in the Regulation, and the inclusion of the recommendations of the report on the State of the Worlds Midwifery 2021. (47)is update should include the standardization of practices, while determining their scope and the competence of each professional category, in addition to a change in the name of the regulatory body from "Nursing Council of Jamaica" to "Nursing and Midwifery Council of Jamaica".the discussions about the review of these Regulations are guided by current debate on the rights of Advanced Nursing Practices; by a general need for updates; to stay in line with current practices and education of nursing and midwifery; and to follow the recommendations of the Benton report (48) and the Council's Strategic Business Plan 2018-2023. (49)garding the future of the regulatory framework, from the perspective of professionals and patients, it must strengthen quality assurance systems so that education and practice standards in nursing and midwifery can continuously attend the needs of the population safely; update nursing and midwifery standards, policies, and directives, so they are in line with scientific and technical developments, as well as best practices; and develop standards and policies to include simulated clinical experiences as part of the study hours required in the course.

Panama
in Panama, the first attempt to regulate the profession dates back to 1940, and since then, has undergone some alterations.the regulatory framework originates from Decree 87, from 1972, (50) , which created the structure of nursing: • Basic nurse; • Starting leader; • intermediary leader; • Higher leader.
Still in regard to legislation, Panama has law 24 from 1982 (51) , which creates the National Nursing Committee, which is formed by nine professionals and eight alternates.the committee has 27 roles related to regulation and surveillance of the exercise of the profession.
there is also a decree from August 28, 2002, (53) which regulates the criteria for the selection processes which shows the country's head nurses.
Regarding professional competence, the National Nursing Committee (54) states that nursing workers have 14 attributions, depending on their level of education., and law 6625, from 2020, (57) which regulates the professional career of nurses in the public sector.Currently, the country has no educational path for nursing auxiliaries, although some of these professionals are still active.On the medium term, this category will be extinguished, with the retirement of the current professionals.law No. 6625/2020 (57) stands out, as it established the Permanent Commission for the Administration of the Professional Career of Nursing Personnel.it is presided by a representative of the Ministry of Health and Social Wellness and composed of nurses.this commission is responsible for the elaborating selection processes to start a nursing career.Advancements in nursing include: the ability to enter the profession via selection process; the regularization of a 30-hour/week workload; retirement at 55 years of age; nursing residencies; certification of nursing specialties; 4,000 professionals to increase personnel sizing during the pandemic; certifications of the quality of nursing services; and nursing internships.At the moment, a directory of specialties is being discussed, and policies in the field of nursing are being elaborated.Challenges include the fact that 55% of nurses are employed, while nearly two thousand remain unemployed, and there are those who have multiple jobs. in addition, the country needs education for caregivers and has been going through a migration of workers, which leads to a reduced national workforce.

Peru
Nearly 70% of health workers are nursing professionals. in recent years, the number of nursing professionals grew substantially.Regarding regulatory frameworks, labor regimes in Peru are varied, both in the public and private spheres.the law that regulates health professionals is from 1982, and also regulates the exercise of nursing workers. (58) the scope of nursing, there are two different work regimes: contracted and nominated.Contracted workers have no career stability.Workers in the private sectors are also considered to be in a contractual regime. in Peru, to be a contracted nurse, one must be graduated.the Ministry of Health offers openings for contracted workers in remote areas of the country.Nominated workers, on the other hand, are stable and follow a special regime, with a regulation of work journeys and shifts.the regime that applies to the entire public administration and health workers was implemented in 2013, via legislative Decree 1153 (59) .it also regulates professional remuneration.in this regime, professionals are paid differently depending on their work, academic background, and the region where they work.this allowed for a better appreciation of professional specialization and the services provided by these workers.low wages were a constant complaint of health workers, as there was a difference of nearly 50% between a physician's and a nurse's salaries.After long struggles and increased recognition, it was possible to reduce this gap to 20%. in this setting, the future of the regulatory framework will be the definition of a norm to regulate the professional exercise of all nursing professionals and other health workers.this single regulation will bring advantages to professionals (reevaluating health workers, improving work conditions, education, and the development of the workforce in order to improve their abilities, in addition to developing their career through promotions and developing the career of manager); for human resource managers (improving the labor climate, the retention of health personnel, and the management of conflicts and human resources); and, especially, for patients (improving health services, access to health services, adequate professional attention, and providing more health services).the Ministry of Health is discussing the alignment of human resource policies.Furthermore, there has been a reform in the health care services in rural areas.

Uruguay
in recent years, Uruguay focused on guaranteeing access to health care to its population.Despite being a small country, it receives immigrants from Argentina, Venezuela, Cuba, and other latin American countries, due to its political and financial stability.Data from 2021 indicates that the country is home to nearly 34 thousand nursing professionals, 6731 of which are licensed nurses, while 27,732 are nursing auxiliaries.that is a proportion of 4.3 auxiliaries for each licensed nurse.the nursing workforce represents 31.2% of the workforce in the field of health.Most nursing workers are female (84%), and most are from 35 to 54 years old (57% of the total number). (11)garding regulations, the country enacted Decree 354/014, (60) , which regulates law No, 18.815, (61) , regarding the exercise of nurses and nursing auxiliaries.Nursing is related with the management of care, and seeks autonomy in its professional exercise, which must receive support from a legislation that allows these workers to make assertive decisions, occupy roles, and act, bringing their practice in line with health needs.this regulation determines the attributions of nursing professionals in regard to direct assistance, research, and education, in addition to providing patients with care and professionals with better work conditions.Nursing law 18.815, from 2011, (61) was discussed for many years and led by several regions of the country, receiving support from the political system. the regulation process included: workshops in several regions of the country, gathering nurses to receive opinions and contributions; the Enferm Foco.2023;14(Suppl 1):e-202301ESP12 in 2011, discussions were held, and the project was approved unanimously.As a result, there is a national nursing council that works with the Ministry of Health to carry out all necessary dealings.the advantages of this process include the fact it led to the creation of a stable surveillance body, despite the changes in political administration and governments, and different transition periods.Challenges for the future include promoting a strong campaign for the appreciation and monitoring of nurses; encouraging the financing of professionalization programs to license nursing personnel with no university education, since all nursing auxiliaries should be supervised by licensed nurses, but this is not always the case; and furthering the regulation of advanced nursing practices.in regard to professional education, the country has professional MS programs in one public university and in five private ones; this number may seem low, but it must be considered that Uruguay is a small-sized country -which is also an advantage in the management of professionals and elaboration of policies.

Caribbean Community Countries (CARICOM)
the CARiCOM is formed by 20 countries (15 member States and 5 associated members) integrated in four pillars: social, economic, security, and external policy.there are similarities and differences between these countries and in the way they educate nurses and midwives and exercise these practices.
However, to achieve integration, there are attempts to find harmony among them through measures such as: 1) regional curricular models and regulations developed for nursing graduates; 2) integration of regional licensing exams for nurses; 3) implementation of a work group for uniform nursing teaching; 4) standardization of nursing and midwifery practices; 5) discussions regarding the creation of a regional curricular model for midwives and their licensing processes.
Although there are attempts to integrate, there are also differences, considering that each country has a regulatory framework for the practice and education of nursing and midwifery.the mission of the Regulatory Councils is to use these frameworks to protect the public as a whole, based on the laws of their respective countries.these councils are formed by medical representatives, local public, nursing authorities, and lawyers that aid the group regarding its legal aspects, reporting the discussions that take place to the government.the role of regulatory authorities include: the last update of the regulatory framework took place in 2017 and needs to be reviewed and updated.Furthermore, regulations are necessary to cover the monitoring of specialists and advanced practice nurses.Some updates address nursing graduation as the entry-level qualification for nurses.Some member-States have statutes mainly concerned with licensing, early registration, renovation of registrations, and removal from registries, often ignoring the scope of the practice and of independent practice, making it difficult for Councils to take disciplinary measures.the reviewing and updating of regulatory frameworks is necessary for the following reasons: changes in education and nursing practice, in the scope of advanced practices, and in the minimum requirements necessary to be qualified to start practice; new categories/specialties of nurses and obstetric nurses who must be regulated to protect the public and the profession; needs for mandatory continued education; and the necessity of reflecting on changes that go beyond a regional integration of practice and education in nursing and midwifery.the future of regulation in nursing and midwifery in the region of the Caribbean depends on reviews and continued updates to ensure that nursing practice and education continue to be relevant and up to date; that nurses and midwives are capable of exercising advanced practices; that the integrity of both professions is maintained; and that public safety is guaranteed.

CONSIDERATIONS OF THE PARTICIPANTS IN THE DEBATE GROUPS
The role of national regulation for health professionals in Brazil, the profession of nurse is regulated by law No. 5905/73, law No. 8967/94, and Decree No. 94.406/87 (21,24,27) . in addition, the Federal Nursing Council and the Regional Councils are organs whose role is delegated by the State to regulate the profession of nursing.the regulatory frameworks, in principle, have the role of increasing the access of the population to the health system and protecting the health of people and populations.in the case of Brazil and Costa Rica, the role delegated by the State to a council that monitors professional exercise and has the power to enact regulations can make it possible to increase access to health services.it also protects nursing health professionals in their practice through the enactment of specific norms for the activities of these professionals and regulate procedures.this guarantees ethical professional exercise and, finally, reduces the risk of disease both in the population and in nursing professionals.

Monitoring of practice and professional
ethics in Argentina, Brazil, El Salvador, Jamaica, Panama, and Paraguay in Panama, there is a Code of Ethics enforced by a group of seven members, elected every three years by an assembly of the Panama Nursing Association. (54)the complaints about unethical behavior and health services are referred to this organ.According to the Code of the profession, since 1947, the chief nurse was already the one responsible for ethics and for the service itself.in Jamaica, on the other hand, there are managers in the services to deal with ethical concerns, which are also considered by those responsible for the human resources of the organizations.One of the functions of the council is ethical and disciplinary, and it can suspend one's professional exercise if necessary.it is formed by 15 members of civil society, and there is a disciplinary sub-council to deal with these issues.in Paraguay, there is a nursing law with a disciplinary scope, but it is not regulated.Since this law is not regulated, the general norms for public servers are used.According to nursing law, a chief in the field can give three warnings to a person (a verbal warning, a written warning, and a third one; the latter is communicated with the maximum authority and can lead to expulsion).there is a Council Ethics Committee, and, in 30 years, there has been a single intervention.in Argentina, as in Paraguay, there is a federal nursing law, from 2004.However, each of the 24 provinces in the country has its own nursing law, each with a specific chapter about sanctions to professional exercise.Also, in some professionals in the career of nursing. in many countries, there is an evasion of nursing professionals due to low salaries and work conditions.Regarding strengths, the capacity for political articulation stands out.there are regulatory laws in the countries in the group, which is, in itself, an advancement.Another strong suit is the fact that each country acts in accordance with its regulation.these laws are called "professional regulation laws".the exam to evaluate professionals, in the Caribbean, is called Regional Exam, and is approved by all countries in the CARiCOM. it is a competence-based exam, administered by the Regional Councils of the Caribbean.in 2014, however, a partnership was established with the Examination Council of the Caribbean, which is an organ responsible for final school examinations and certification examinations for higher education institutions.the current exam is based on competences, covers great areas, and is reaching its goals regarding the regulation and evaluation of the beginning of professional practices.
in Argentina and Brazil, this type of evaluation does not exist yet.Uruguay carries out this examination, but, as of yet, it remains unregulated.Colombia is starting to carry out peer evaluations, and Panamá has a competence examination.
the USA has the "NCLEX Exam", with two versions -one for Registered Nurses, and another for licensed Practical Nurses.this is a competence-based exam which evaluates several domains.Each item is tested before being applied and all questions are validated.the exam is carried out using the computer, and, after each correct answer, a harder question is presented.if a mistake is made, the participant goes back to an easy question.thus, the level of ability is ascertained.there is a cutoff point, and those who reach that grade pass the exam.
Canada works with continued education, verifying how each professional seeks further qualification.the professionals are the protagonists here, as they see their own limitations and analyze their needs.they are responsible for self-evaluation, in addition to determining their learning needs, the gaps in their knowledge, and their learning opportunities. the evaluations take place every year and are necessary for professional registration.Some nurses who undergo the self-evaluation are randomly selected to participate in a more thorough process of practice review.this takes place in most Canadian provinces, with the exception of Quebec, were there are demands for continued education and professionals must work for a certain number of hours. in both instances, leaders determine the requirements for continuous competences that the professionals have to achieve; this is the actual self-regulation process.the power of regulatory authority is based on regulatory bodies, and nursing professionals make decisions regarding their profession.
In the USA, all states use the "NCLEX Exam", and all those who want to become nurses must pass said exam. it is available 24/7.One enrolls in a testing center, goes to the center, and undergoes the examination.the centers are open throughout the year and, thus, students do not need to wait to start their professional practice.the number of attempts a student can have varies from one state to another.if a student passes the exam, they are safe to start their professional practice.Whether the student passed in their first, second, or third attempt, they will not be discriminated against due to the number of attempts.if the person fails more than six times, a verification is made as to what can be done, and where the student is failing. in this case, they get feedback on their failings.Some may need further education, as, in the USA, if the candidate does not pass the exam, they must receive further education on the subject.Generally, they need to study alone or go back to their original teaching institution.there are no restrictions in this regard, but the student will not be able to practice until they are approved in the exam.the national approval rates are 87% in the first try, although there has been a drop in approvals due to the COViD-19 pandemic.School directors state that practice must maintain its levels of safety, and, therefore, the grade required to pass the exams will not be reduced.Passing the examination means the student will be able to practice nursing safely. in addition to verifying why the person failed the exam, it is important to analyze the performance of their colleagues.thus, all students from a specific program are analyzed, and the directors of these programs get feedback, which allows identifying failures in their curricula.this is one of the mechanisms used for regulators and educators to work together, since all recognize the value of the profession, and it is possible to collaborate with nursing schools to check potential weaknesses of their programs.in the Caribbean, approval rates vary from country to country, with a minimum of 50% and a maximum of 86%.
Regarding the number of attempts a student can make to pass the exam, the maximum is three.After the third failing, the student must go back for further training or choose a new exam, which can enable them to practice in a lower level than that of their education.Recently, the number of attempts was increased to four, with a recommendation, at the third failure, for the student to undergo some form of mediation.if they fail again, either they will need further In Brazil, a law from 1986, (21) regarding the regulation of the professional exercise in nursing does not address advanced nursing practices.in addition, the legislation that authorizes distance nursing courses must be reviewed.
According to some professionals, there must be advances towards the implementation of an exam to be registered in the nursing councils.Furthermore, in Brazil, there is no need to provide proof of continuing education to maintain or renovate one's professional record.
In Colombia, regulatory frameworks were updated, but still need change.the country is working towards regulating continued education, as not doing so could compromise the quality of the care provided to the patient.
Costa Rica has had a regulatory framework for more than 50 years.the country's Medical Council already examines its professionals before they can start their practice, and the Nursing Council has partnered with these physicians in order to carry out their examination.the Nursing Council is responsible for providing continued education to all collegiates, which it does, free of charge, on virtual platforms.

CONCLUSION AND NEXT STEPS
the Forum has shown that the regulation of nursing professionals of several countries needs to be updated.the participants of the Forum highlighted the following recommendations as proposals for future action: • to promote a national debate with all key-actors, including the Ministries of Health, Education, and Work, in order to develop regulations in these countries.
• to develop intersectoral articulation about the topic of regulating Human Health Resources.
• to generate a common data bank to identify and gather information about regulations and guide regulatory organs.
• to review the competences of regulators and invest in providing them with further education.
• to broaden research on the topic and train regulators to generate and analyze data.

FiNAl
REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.Decent work and economic growth are the 8th objective of the WHO's Sustainable Development Goals (SDGs).
Health services could not allow students to undergo clinical internships during the pandemic, since their facilities were unavailable; thus, simulations were used to test the practical ability of the students.this meant graduates had less contact with patients.Another impact involved difficulties recruiting and retaining talents.Since work demands had grown and the number of workers was smaller, there was a greater amount of work per person.Younger persons were less motivated with the mission of the profession, but more motivated with the idea of having a more flexible balance between life and work, asking what advantages the employer could provide. in this setting, some strategies and benefits are important, such as the opportunity provided by scholarships; Enferm Foco.2023;14(Suppl 1):e-202301ESP12 3 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al. the reimbursement of student loans; educational partnerships and career progress programs; additional internship opportunities for health students to support their transition into practice; nursing residencies; local recruitment to facilitate worker retention; and providing health field programs to elementary and high school students, in addition to bonuses, flexible work hours, and hybrid work models.in New York (USA), a program was released for nurses who wanted to work in the community, facilitating the process of license acquisition and portability, which optimized the possibility of working in other states, and increased the adherence of these states to this practice during the pandemic.the main factors that difficult worker retention are stressing work conditions, especially those involved direct patient care, which lead to exhaustion; personal and family security issues; the search for better pay, in or out of the health field; family obligations (caring for children or older relatives); and transportation issues, especially in larger cities.It is essential to establish data-based strategies to give support to the development and retention of the nursing workforce, while providing incentives for professionals to relocate to regions with no attention, thus giving support to work/study partnerships between health workers and nursing education programs and focusing on the mental health of workers, as well as on the construction of efficient and collaborative health teams to attend the patient.
fessional exercise.the Ministry of Health coordinates this certification through the National Commission to Assist University Graduation Professions and the Federal Council of Health.Health careers establish the labor framework of public health workers.they are sanctioned by each jurisdiction.Collective work agreements deal with the specific labor relation agendas of certain groups in the private sphere.University education is regulated by the Higher Education law, (13) which standardizes the certificates of graduation careers and the scope of each profession.the country also has a National Program of Nursing Education (PRONAFE), whose goal is increasing the amount and quality of higher education technical courses in Argentina by giving institutional and academic support to higher education public management private institutions that provide the course.
ment of the process of promotion and development started by the PRONAFE; generates innovative state capabilities and coordinator organisms, such as the National Commission for the Formation and Development of Nursing in the Republic of Argentina; incorporates the certification of technical careers; determines that resources to encourage and contribute to education should not be below 2% of the budget of the Ministry of Education; and determines the bases for the promotion of continuous professional education and the development of advanced practices.Argentina must standardize the regulatory framework of these professions.For Advanced Practices in Nursing, it must incorporate the processes of formation, and change the norms and attributions of professional exercise.

Enferm Foco. 2023; 14 (
Suppl 1):e-202301ESP12 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.Regarding regulations (rulings, auditing, sanctions, positive incentives to good behavior, and collective arbitration), the normative elements are the most visible ones.the Union has authority over states and municipalities, which helps standardize the regulatory context.the regulation of health professions involves three great areas: • Regulation of the EDUCAtiON of health workers (technical, graduation, and specialization) in regard to the National Curriculum Standards (NCS).• Regulation of the PROFESSiONAl EXERCiSE (registration, ethics, legal competences, and permitted activities in accordance with training and education).•Regulation of WORK RElAtiONS in the field of health (work hours, salaries, careers, etc.).
ing not only the Ministry of Health, but also the Ministries of Work, Education, and the Ministry of Planning, Budget, and Management.Depending on the specific profession, other Ministries may also be involved.Within the Union, there are also other authorities, in the form of the Professional Councils of each profession -of which there are 13 in the field of health.these are autonomous authorities with regulatory powers, and each council only has power over their specific professionals.Councils elaborate norms about the professions, and all have the same hierarchical level, with no council having authority over another.Some rules and prerogatives can also be elaborated by the Ministry of Health, which has a greater political import for their implementation.Within the Ministry of Health there are also important collegiate organs, such as the Secretariat of Work Management and Education in Health (SGtES) and the National Permanent Negotiating table of the Unified Health System.the regulation of the exercise of health technicians is still decentralized and fragmented.Professional Councils regulate several aspects of the exercise of a profession, including, especially, deontological aspects (ethics), the scope of the practice, and the definition of specialties, in addition to conceding the title of specialist.Each council can edit their norms, which become valid to all registered professionals.Currently, there are no spaces for conflict mediation or for the construction of normative spaces (which are especially necessary to determine the scope of the practices and define their specialties).in case of any conflict, discussions are held in judicial courts.in Brazil, all regulations of professional education are determined by the Ministry of Health, which regulates higher education, as well as stricto sensu and lato sensu (specialization) post graduations.Professional Councils establish the rules to confer the title of specialist.However, different councils have different rules for conferring titles.

(Chart 1 .
COREN) are organizations created by law, by the Brazilian State (law 5905/1973) (27) , to discipline, regulate, and audit the professional exercise of nursing in the national territory as a whole, including administrative law enforcement powers.their core activities include ethical and technical monitoring of professional exercise, as well as the provision of authorizations to exercise the profession, among other responsibilities.Before the advent of this law, the Ministry of Health was responsible for supervision.this category represents 53% of the health work force in the country.in the last few years, there has been a process of expansion in the teaching of nursing in Brazil, especially in the categories of auxiliary and technician.Current challenges include professional education, quantity versus quality, difficulties to enter the job market, more demands for quality in the services, and low wages.Priorities to regulate the profession include work hour regulations (in Brazil, 44 hours per week) and the minimum legal salary for the category.the actions of Nursing Councils and their roles of monitoring, guaranteeing ethics, and regulating professional exercise are essential for the population to appreciate and recognize the importance of these professionals.Canada Canada is a large-sized country, with a population of 38 million people. it has 10 provinces and 3 territories, with 26 institutions that regulate nursing among them.in Canada, there are four different categories of nurse: Registered Nurse (RN), which requires nursing graduation; Licensed Practical Nurse (lPN), which requires a diploma; Registered Psychiatric Nurse (RPN), which require nursing graduation and approval in the Registered Psychiatric Nurse of Canada Examination (RPNCE); and the Nurse Practitioner (NP), which requires a post-graduation.Figure 3 shows the composition of the Canadian nursing workforce.thereare approximately 400 thousand nurses in Canada.Regarding the role of the provinces and territories in the Regulation of Nursing in Canada, there are 13 different systems.Each province or territory chooses how to regulate its professional categories.the federal government is involved in the distribution of financial resources, especially in regard to regulation, but provinces and territories determine how to use these resources.Nurses are ruled by the legislation of each province and territory, which outlines general standards and creates regulatory bodies that can define and enforce the specific requirements and responsibilities of each profession.Regulation is a continuum, from the legislation of provinces and territories to the detailed lining up of directives, regulations, and norms of regulatory bodies.in Canada, the scope of nursing practices is regulated, the professional title is protected, there are mandatory educational requirements, and a set of professional standards for practice, in addition to a process of professional supervision, all of which are specific for the jurisdiction where the nurse is licensed.Regulatory bodies have the duty to protect the public through the establishment of requirements for professional practices (approval in educational programs, competences, and exams); the articulation and promotion of standards of practice (directives, definitions of the scope of practice); the administration of a quality assurance program (continuous maintenance of competences); and the application of standards of practice and conduct.it is also noteworthy that there has been an effort to modernize regulations, which takes place especially through the incorporation of "right touch" regulatory principles (table 1); regulatory collaborations -which are very important, especially in territories with more than one regulatory agent; and evidence-based result-oriented approaches.there have also been analyses about how professionals with a similar scope can work together.As mentioned above, there has been a total of 26 regulatory institutions in Canada.Although, ultimately, the main responsible for the regulations are the regulatory institutions in the provinces and territories, three organizations joined forces to increase communication and coordinate regulatory activities.these were: the Canadian Council of Registered Nurse Regulators (CCRNR), the Registered Psychiatric Nurse Regulators of Canada (RPNRC), and the Canadian Council of Practical Nurse Regulators (CCPNR).these agencies formed the Canadian Nurse Regulators Collaborative (CNRC), whose goal is providing a forum where regulatory nurses can exchange knowledge and information, facilitating collaboration and organizational alignment.there is an ongoing pilot work aimed at promoting a multi-jurisdictional registration of nurses involving three jurisdictions (British Columbia, Alberta, and Saskatchewan), in order to provide nurses with portable licenses between these territories, reviewing alignment and requirements of language proficiency -in addition to efforts to simplify the integration of nurses from other countries.Enferm Foco.2023;14(Suppl 1):e-202301ESP12 Principles of the "right touch" regulation Equity: recognizes that each person has their own circumstances and requires different resources and opportunities to reach the same result.

•
law 1438, from 2011 (31) -Art.97, Human talent: the Ministry of Health and Social Protection, considering the recommendations from the National Health Council of Human talents in Health, will define the policy of human talents in health to guide the education, exercise, and management of professions and occupations in the field of health, in accordance with the needs of the Colombian population and the characteristics and goals of the General System of Social Security in Health.the regulatory framework was elaborated in 1996, (32) by the National Association of Nurses of Colombia, with support from Canadian nursing.this is the law that regulates professional exercise in Colombia, and although it is quite advanced, it still needs adjustments.this law created, in 2004, the National Ethical tribunal of Nursing, and, with the creation of this tribunal, the code that rules the exercise of nursing was established.Decree 7/80 established an articulation between the ministries of health and education and created an intersectoral mission for the development of a technical level for health workers.A technical plan for 10 years was elaborated and managed to organize nursing and related collegiates (organs responsible for the registering of graduated professionals).

lating
Health Science professionals (General law of HealthNo.5395, from 1973).(33)Recently, in 2019, the Unit of Human Resources for Health and the Regulation of Professional Profiles in Health Sciences were created by Executive Decree No. 41541-S.(34)  in 2020, the professional collegiates were asked to determine the professional profile of the generalist nurse, which, currently, is still being reviewed.One particularity of the country is that two organizations share the responsibility of regulating health workers: the Ministry of Health and the Professional Councils.the Ministry of Health, as a regulatory body, is guided by the General law of Health and the Executive Decree No. 41541-S(33,34)  , which defines the profiles of health professions.For health professionals to register in the professional councils, they must undergo Mandatory Social Services (SSO).theCouncils are non-governmental entities responsible for elaborating the professional profiles; creating certificates for professional governance; monitoring professional exercise; and promoting continued education.legislation, through Art.40, from the General law of Health(33)  , clearly governs the specialties that belong to Health Sciences: Pharmacy, Medicine, Clinical Chemical Microbiology, Enferm Foco.2023;14(Suppl 1):e-202301ESP12 9 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.Dentistry, Veterinary, Nursing, Nutrition, and Clinical Psychology.Currently, 8 professional profiles have already been reviewed and approved; 75 have been reviewed; and 4 are yet to be contemplated by Art.40 of the General law of Health, but were already reviewed and approved.As it happens in other countries, challenges to regulate Health Science workers involve updating regulatory frameworks; managing human resources; policies for hiring and retaining nursing personnel; the emigration of professionals to other countries, such as the United States, Canada, and Germany; national health policies and the transcendence of the intermediary role of the Ministry of Health; and advancements in discussions to establish a guide that can incorporate requirements that go from the education of professionals to employment entities, in addition to an articulation with professional councils for the elaboration of professional worker profiles and monitoring. in Costa Rica, the creation of any profile in Health Sciences requires approval from the competent regulatory bodies, as well as dealing with several government institutions and the Ministry of Education itself.the central issue in this regard is, currently, the need to focus on the formation and regulation of nursing workers in the country, and participating in the formalization of public policies, such as the national policy to develop human resources in health, in order to regulate the excellence of health in Costa Rican nursing.
the current situation of the country can be characterized, regarding its geographical distribution, by a population concentration in cities, and a lack of nurses in rural areas.Standards of care and the Ministry of Health recommend that there should be a nurse for every 12 patients.Regarding their work journeys, for a period of time during the COViD-19 pandemic, the work shift changed from 7 to 12 hours, and the extra work hours are still being required.Regarding public policies, their goal is to improve and provide quality education to professionals and students through scientific research.the search for improvement includes the encouraging of research, continued education, specializations, advanced practices, curriculum revisions, professor updating, and public and policy leaderships.Concerning regulatory frameworks, certain actions stand out, such as: improved conditions for hiring; establishment of salary structures, according with the education of the professionals; improved work conditions; improved quality of care; establishment of mechanisms of quality control; and a provision of necessary materials and resources.El Salvador in El Salvador, there are four main actors in the regulation of nursing: the Ministry of Health; the Higher Public Health Council, responsible for the health of the population and for enforcing the law; the Surveillance Board of the Nursing Profession (JVPE) -institution that regulates the exercise of nursing and is integrated into the Public Higher Education Council; and the Ministry of Education, Science, and technology, which is responsible for academic regulation and supervision.in the scope of the Constitution of the Republic of El Salvador, the JVPE is formed by nursing academics and can suspend the professional exercise of association members who exercise the profession with flagrant immorality or inability.the Higher Public Health Council, in turn, acknowledges and settles appeals against the resolutions of the JVPE.Regarding the Health Code, the Ministry of Health is responsible for the development and improvement of Enferm Foco.2023;14(Suppl 1):e-202301ESP12 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al. educational norms of these professions, in addition to promoting technical training and the specialization of the personnel responsible for health services.there are no nursing specializations in the country, but, in 2022, MS courses in nursing were implemented.the JVPE regulates and exercises control over the profession in its technical and auxiliary activities.the Code also provides permanent, temporary, or provisional working licenses.Regarding the National integrated Health System, the Ministry of Health, as a government entity, aims to elaborate the National Health Policy and Plan, in addition to coordinating and encouraging plans and programs to educate, train, update, and manage health workers.the Higher Public Health Council is responsible for monitoring and evaluating the execution of norms and protocols concerning the guarantee of the quality of services provided by the institutions that are part of the System, including the Ministry of Health as a service provider; the private sector; and the non-profit organizations, providing all pertinent recommendations.the Higher Education law prescribes six academic degrees, corresponding to the different levels of higher education: a) technician; b) teaching staff; c) technologist; d) licensed, engineer, and architecture; e) master's; and f) doctorate.Currently, according to law, only dentists and physicians have available specializations.From 2000 on, the National Nursing Unit, partnered with educational institutions, standardized study plans for the academic degrees of nursing licensees, technologists, and technicians, which are references for private teaching institutions.the System for the Supervision and Quality improvement of Higher Education institutions requires the Ministry of Health to be responsible for qualifying, evaluating, and certifying educational entities.Currently, the National Coordination of Higher Education requests the opinion and approval of the National Nursing Unit regarding nursing study plans, so these can be authorized by the Ministry of Education, Science, and technology.Furthermore, the JVPE reviews and provides official opinion on study programs, which are later approved by the Higher Public Health Council. the National Nursing Unit is responsible for regulating, assisting, conducting, and controlling, so the nursing care provided to people in their life cycles, in different levels of care, is of good quality, humane, and free from risk. the regulation and standardization of nursing practice has been pushed forth by a joint effort of institutions of education, services, and the national association, through different regulatory documents which, according with their goals, are grouped into policies, norms, technical-administrative guides, and organizational manuals. in El Salvador, the regulation of nursing and its different levels of human resources is regulated by the State and controlled by the nursing workers elected to form the JVPE. the members of the Higher Public Health Council are elected, every two years, by nursing workers.the professional exercise is coordinated by the Council for the Supervision of the Nursing Profession, through the control and surveillance of the exercise of the profession.Regarding the scope of professional performance, the Ministry of Health regulates the provision of nursing care through the National Nursing Unit. the future of the regulatory framework for nursing in the country revolves around new master's degree courses (at time of publication, there are only two such courses in nursing: intensive care and mother-child care); specializations and residency in nursing; and the law of Higher Education.it is noteworthy that, in 2021, the Minister required a study from the National Nursing Unit to implement specializations and residencies, and the Unit requested a revision in order to reformulate the Higher Education law to allow the incorporation of specializations not only for nursing, but also for other courses.United States of America in the USA, licensing agreements allow nurses to have a license in their native state while having permission to practice in others.this provides better information from the perspective of the workforce.the Nursys system from the National Council of State Boards of Nursing is the only national database to verify the licensing, discipline, and scope of nursing practice.it has a public version and another for regulatory agents.it is useful to exchange information among interested parties and to protect the population.A model is being developed for disciplines to communicate among themselves.the next generation of the National Council Licensure Examination (NClEx), which is a national examination to license nurses in the United States, Canada, and Australia, will include clinical competence and decision-making questions.Guyana in the scope of university education, the highest degree of nursing education in Guyana is that of graduation (university level).the country has no MS or PhD programs, however, it partners with Collaboration Centers from the PAHO/WHO in other countries to graduate its nursing professionals.Regarding regulatory frameworks, the Enferm Foco.2023;14(Suppl 1):e-202301ESP12 11 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.show inefficiency, with no optimization of resources and little implementation of mechanisms of control, monitoring, and evaluation to improve the efficiency and efficacy of the process and manage human resources.Factors that facilitate the establishment of the regulatory framework, in turn, are: the Civil service law and its Regulation(44)  , which establishes disciplines and rules for the performance of the nursing personnel; collaborations with public and private universities; availability of higher education programs for the education of nursing professionals; a Public Policy of Human Resources for the National Health System; updating and readapting Post-Graduation Regulations; providing 30 post-graduation scholarships to nurses; and signing an agreement for education, training, and support in health services.in Honduras, 3 MS programs will be concluded soon, educating 80 professionals in this level.there is also a course to form licensed nurses, which has, as one of its requirements for participation, being a nursing auxiliary.For this purpose, the students will receive a scholarship-salary.it is noteworthy that the country needs nursing workers and educational programs with clear directives, that allow consolidating and advancing nursing.in the scope of Public Health, the market requires professionals to be flexible enough to adapt and undertake new challenges.Some tasks that must yet be done include planning, providing, and assessing nursing care for patients, according to modern nursing practices and standards; coordinate the care to patients with other health workers and members of the health team; develop and apply health care plans to treat patients, collaborating with other health workers; organizing and providing personal care, treatment, and therapy (including drug administration and monitoring of reactions) for treatments or care plans; planning and participating in health education programs, to promote clinical nursing education activities and community centers; supervising and promoting the work of other nursing professionals; researching about nursing practices and procedures, disseminating the results through reports and scientific reports. in Honduras, certain needs allow consolidating and giving support to the advance of nursing, such as: a review of the academic curriculum; professor academic development; updated human resource public policies; and work stability.Jamaica the Nursing Council of Jamaica, established in 1952, (45) is a government organ that regulates and controls nursing and midwifery professionals. it has 15 members, named by the Ministry of Health and Wellness, including nursing workers, Council of Nurses and Midwives was created by law No. 7 from 2022. (42)During the tenure of the current president of the country, a regulatory framework was developed in the form of a semi-autonomous body model, responsible for enrolling, registering, certifying, and providing licenses to nursing personnel; establishing educational standards and requirements to start in the profession; monitoring the conformity of educational nursing institutions; developing a code of ethics and conduct, thus establishing regulations, since previously there were only directives; providing continued education for nurses in all levels of education; and guaranteeing that health personnel will exercise the profession in an ethical manner, within a legal structure.Many nurses are immigrating, but there have also been professionals who left Guyana towards other countries.immigrant nurses are believed to be working irregularly in the country.there must be guarantees for dignified work, and these professionals must be regulated.the Government is aware that the country is in the midst of a development boom due to investments in oil. the future of the regulatory framework involves: focus on nursing regulations and new areas, in accordance with other countries in the Caribbean; application of regulations for public entities and private ones; creation of licenses for specialized fields (for example, pediatric nursing, and others); revision of regulations to increase the scope of nursing practice; collaborations with regulatory bodies and teaching institutions; enhancement of the competences of nurses in environments of practice, with innovations and research; accreditation of nursing schools; direct access to the graduation course in nursing at the University of Guyana; registration of a larger number of nurses and obstetric nurses, due to their hybrid curricular approach; increased admission of students; and a decentralization of nursing schools in the region.Honduras Honduras has 20 health regions, distributed in 66 service areas, with 14 nurses per 10 thousand people.the Constitution of the country establishes what will be the model defined by the government, and creates the statute of professional regulation. (43)the legal framework is in the Constitution of the Republic (Chapter Vii, of health); in the Organic law of the Nursing Professional Council; and in the Regulation for the Organic law of the Nursing Professional Council.these documents mention all work conditions of nurses in Honduras.the factors that limit the establishment of the regulatory framework are hospital indicators that Enferm Foco.2023;14(Suppl 1):e-202301ESP12 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al. two representatives of the general public, and one legal aide.
to nurses: right to food (at hospitals); right to additional pay due to the risky nature of the job; payment for extra shifts; right to an extra 40% payment for work in areas that are difficult to access; right to free housing in places of difficult access; right to work 6-hour shifts in stressful areas; two days of recess for every weekend working in vaccination; and 30 days of vacation, with 15 additional rest days, recognized by law.law 43 from 2004, modified by law 32, from June 3, 2008, (55) established the regime for the certification and re-certification of health workers, and created the "interinstitutional Council for the Certification of Basic Nurses". it also established the law of Nursing Protection, which authorizes the Ministry of Health to hire, temporarily, foreign health workers and technicians to provide professional services.Paraguay the Paraguayan health system has a segmented model, formed by a public subsector, a hybrid subsector, and a private subsector.in fact, the legislation currently guarantees free health care access to the population of the country.law 3206, from 2007 (56) , regulates the exercise of nursing in the public and private scopes, associating three laws: the National Directives for Register and Control of Health Professions; law No.3206 from 2007, about the Exercise of the Profession of Nursing;
determining standards for the education and practice of nursing; determining the process for licensing, registering, and renovating registrations; promoting enrollment and the renovation of enrollment, certification, and renovation of the certification; establishing codes and directives for professional conduct; monitoring adherence and investigating violations of ethical regulations; responding to notifications and complaints about professional conduct; raising interest about nursing and midwifery professions; and approving and accrediting education in the form of training programs and nursing and midwifery schools.Regarding the current situation of the nursing and midwifery regulatory framework in the Caribbean, most CARiCOM member-States have a unique regulation for nursing and midwifery, while the others have a separate one.
provinces, there is a Council or Ethics Committee formed by different professionals in the field of health.Regarding the topic of ethics, the Argentinian Nursing Federation is formed by organizations from each province, which also have their ethics councils.in El Salvador, there is a regulatory body: the Surveillance Board, with five nursing professionals.this organ is part of the overarching regulatory framework in the health code of El Salvador.it regulates the exercise of the profession and provides licenses.this organ also has nursing inspectors.there are five of them to attend the country as a whole.Different sanctions are possible, depending on the nature of the topic.there is another organ with three branches: Ministry of Health, Surveillance Board, and the Higher Public Health Council. it is important to note that the president of the Higher Council is chosen by the nation's president. in Brazil, one can say that councils have supervisory powers, and their supervision is based on professional organizations. in the 1970s, the Federal Nursing Council (Cofen) and the Regional Nursing Councils (Coren) were created as organs to discipline and supervise the exercise of nursing.All nursing professionals provide financial contributions to maintain the Federal and Regional councils.these councils are autonomous and, since 1955, nursing has had a law for professional exercise.in 1966, a new law was enacted, which became a milestone for the professional roles of nurses, nursing auxiliaries, and nursing technicians.it is worth highlighting that the Cofen regulates the exercise of the profession and its ethical aspects, and elected full-time council members whose function is, exclusively, supervising the exercise of the profession and keeping professional ethics.these persons are chosen via electronic votes, every three years.Strengths and weaknesses of nursing practice regulatory frameworksthe first weakness found was the excess of nursing activities, which makes oversight more difficult.Countries presented a mean of 26 key-activities associated with the profession, and their regulatory frameworks are unable to provide supervision due to the dimension of these activities.there are also hardships involving communication between nursing workers, and regulating the quality of nursing education represents another challenge.Regulatory frameworks do not have the necessary power to supervise and regulate the education of nursing workers. in addition, there were discussions regarding the distance between professionals and the law of professional exercise.Regulatory frameworks and supervisory organs are distant from the education of professionals.this has a significant impact, since these workers, during their education, do not become familiar with their duties and rights, nor with the activities they are legally allowed to do or prohibited from doing.Another weakness found was associated with difficulties in retaining Enferm Foco.2023;14(Suppl 1):e-202301ESP12 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.

Enferm Foco. 2023; 14 (
Suppl 1):e-202301ESP12 17 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al. training, or they will have to undergo an exam for another professional practice.UPDATING OF REGULATORY FRAMEWORKS Argentinian regulations are fragmentary, but regulatory frameworks about the exercise of the profession are up to date.there is a functional National Council of Health, and license renovations are required in most provinces.there must be professional regulators that know their functions, competences, and the local health system.the training of regulators and decision-makers follows a federal model, and there is a Permanent Assistant Commission of Nursing at the Ministry of Health.Argentina has failed to ratify the 149th ilO international agreement, and there are several bills in the country's chambers to address elements related to this agreement.

Enferm Foco. 2023;14(Suppl 1
):e-202301ESP12 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al. the development of the leadership abilities of nurses for the next generation of nursing and obstetric leaders.

the Sistema Enferm Foco. 2023;14(Suppl 1
):e-202301ESP12 5 FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.
FiNAl REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.
REPORt FROM tHE FORUM ON NURSiNG PRACtiCE REGUlAtiON iN tHE REGiON OF tHE AMERiCAS Cassiani SH, Dias BM, Durães MD, Almeida BG, Palha PF, Ventura CA, et al.