Nursing practice environment and missed care at highly specialised hospitals in Mexico: A cross-sectional observational study.

BACKGROUND: The influence of the work environment on missed care and service quality has been well documented. However, available evidence concerning this relationship comes mostly from developed countries. Few studies have been conducted in low- or middle-income countries. We assessed the relationship between the work environment and missed nursing care in highly specialised hospitals in Mexico. METHODS: We conducted an observational cross-sectional study with data collected from January 2019 to February 2020 in 11 highly specialised hospitals (n = 510 nurses). We estimated missed nursing care utilising the MISSCARE questionnaire and used the Practice Environment Scale-Nursing Work Index instrument to assess the work environment. After describing the main attributes of the study sample according to the type of work environment, we constructed five adjusted fractional regression models, the first concerning the overall index of missed care, and the others pertaining to its various dimensions. RESULTS: The sample analysed was balanced as regards adjustment variables according to the type of work environment. The adjusted estimates confirmed an inverse relationship between the missed care index and enjoying an enhanced, or favourable, work environment. Overall, the difference was 9 percentage points (pp); however, by dimension of missed care, the major differences between enhanced and attenuated, or unfavourable, work environments were registered for basic care, followed by patient education and discharge planning (4pp) and individual needs (8pp). CONCLUSIONS: The work environment determines the frequency of missed nursing care, both overall and by dimension. Nursing managers need to create short- and mid-term strategies favouring positive work environments in order to improve working conditions for nursing professionals.

Missed nursing care in highly specialized hospitals: A Mexican case study.

OBJECTIVE: To assess the status of missed nursing care and the reasons for its occurrence in a highly specialised public hospital in Mexico. MATERIALS AND METHODS: An observational cross-sectional analysis with data collected from January to June 2019 at the National Institute of Rehabilitation Luis Guillermo Ibarra Ibarra in Mexico City. We assessed missed care and its causes by conducting the MISSCARE survey among 116 nursing professionals selected from a population of 162 nurses. This work presents the estimated rates of missed care-overall and broken down into its four dimensions-as well as the reasons for its occurrence, namely limited labour resources, inadequate material resources and communication problems among work teams. RESULTS: The overall score for missed care was 16% (95% CI: 11.84%-20.15%), with the following rates by dimension: 19.48% for basic care, 14.66% for individual needs, 6.47% for patient education and discharge planning, and 4.31% for continuous patient assessment. The main reason cited for missed care was inadequate material resources, followed by limited labour resources and communication problems among work teams. CONCLUSION: Basic care and individual needs interventions were the most frequently omitted services, primarily because of inadequate material resources, limited labour resources and communication problems among work teams. An increase in the frequency of missed care can be expected in light of the high demand for health services, particularly as regards labour and material resources, imposed by the SARS-CoV-2 pandemic.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom.

AIM: The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom. BACKGROUND: In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies. EVALUATION: Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational. KEY ISSUES: Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed. CONCLUSIONS: Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation. IMPLICATIONS FOR NURSING MANAGEMENT: The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.

Distance learning and patient safety: Report and evaluation of an online patient safety course.

Patient safety is a critical topic in health care globally, with implications for nurses, physicians, administrators, and most importantly, patients and their well-being. Online distance learning (ODL) is widely accepted among most disciplines in higher education and has been used to promote patient safety knowledge among health care students and professionals in diverse contexts. This article reports on an online Nursing and Patient Safety course developed in 2012 by the University of Miami School of Nursing and Health Studies in conjunction with the Pan American Health Organization and the International Network for Nursing and Patient Safety. The study's objectives are to describe the implementation of an international ODL program to enhance patient safety knowledge in nurses and nursing students, and to examine the participants' assessments of this online approach as an effective learning tool. Most participants who completed the Nursing and Patient Safety ODL course reported being satisfied with the course content and experience, and demonstrated increased knowledge on patient safety, as measured by post-module quizzes and self-report. Limitations of the study include the lack of a comparison group, disparity in the number of participants across the course's language formats (English, Portuguese, Spanish), and the large number of participants who registered for but did not complete the course. Future research should identify obstacles to course completion, explore participants' awareness of patient safety issues and perceived need for more instruction, and look at ways to disseminate the course to the broadest international population of nurses and nursing students.

La seguridad del paciente es un tema fundamental en la atención de la salud a nivel mundial, con repercusiones para los enfermeros, médicos, administradores y, lo que es más importante, para los pacientes y su bienestar. La educación a distancia en línea está ampliamente aceptada en la mayoría de las disciplinas de enseñanza superior y se ha empleado para difundir los conocimientos en materia de seguridad del paciente a los estudiantes de atención de salud y los profesionales en diversos contextos. En este artículo se informa sobre el curso en línea de enfermería y seguridad del paciente creado en el 2012 por la facultad de enfermería y estudios de salud de la Universidad de Miami, conjuntamente con la Organización Panamericana de la Salud y la Red Internacional de Enfermería y Seguridad del Paciente. Los objetivos del estudio son describir la ejecución de un programa internacional de educación a distancia en línea para mejorar el conocimiento sobre la seguridad del paciente de los enfermeros y los estudiantes de enfermería, y examinar las evaluaciones de los participantes sobre este enfoque en línea como herramienta eficaz de aprendizaje. La mayoría de los participantes en este curso afirmó sentirse satisfecho con su contenido y experiencia, y demostró un mayor conocimiento sobre la seguridad del paciente, de acuerdo con las mediciones de las encuestas posteriores al módulo y la autoevaluación. Entre las limitaciones del estudio se aprecia la falta de un grupo de comparación, una disparidad en el número de participantes entre las diferentes versiones lingüísticas del curso (español, inglés y portugués) y el gran número de participantes que se inscribieron sin llegar a finalizar el curso. Las futuras investigaciones deberán indicar cuáles son los obstáculos para la finalización del curso, explorar la concienciación de los participantes en temas relativos a la seguridad del paciente y las necesidades que perciben de una instrucción más profunda, así como considerar modos de mayor difusión del curso en la comunidad internacional de enfermeros y estudiantes de enfermería.

A segurança do paciente é um tema fundamental para a assistência de saúde em todo o mundo, com implicações para enfermeiros, médicos, administradores e, mais importante ainda, para os pacientes e o seu bem-estar. A educação à distância online (EDO) conta com grande aceitação na maioria das disciplinas do ensino superior e tem sido utilizada para transmitir conhecimentos sobre segurança do paciente a estudantes e profissionais da saúde em diversos contextos. Este artigo descreve um curso online de Enfermagem e Segurança do Paciente desenvolvido em 2012 pela Faculdade de Enfermagem e Estudos da Saúde da Universidade de Miami, em conjunto com a Organização Pan-Americana da Saúde e a Rede Internacional de Enfermagem e Segurança do Paciente. Os objetivos do estudo são descrever a implementação de um programa internacional de EDO para melhorar os conhecimentos de enfermeiros e estudantes de enfermagem sobre segurança do paciente e examinar a forma como os participantes avaliaram a eficácia desta abordagem online como uma ferramenta de aprendizagem. Em sua maioria, os participantes que completaram o curso online de Enfermagem e Segurança do Paciente afirmaram ter tido uma boa experiência com o curso e estar satisfeitos com o seu conteúdo; além disso, demonstraram maiores conhecimentos sobre segurança do paciente, medidos por questionários aplicados após os módulos e pela autoavaliação. As limitações deste estudo incluem a falta de um grupo de comparação, a disparidade no número de participantes nos diferentes formatos do curso (inglês, português, espanhol) e o grande número de participantes que se inscreveram mas não completaram o curso. A pesquisa futura deve identificar os obstáculos à conclusão do curso, explorar a conscientização dos participantes sobre questões de segurança do paciente e a necessidade de mais instrução e procurar formas de divulgar o curso para uma população internacional mais ampla de enfermeiros e estudantes de enfermagem.

Advanced Practice Nursing Roles: A Comparison Between Mexico and the United Kingdom.

The COVID-19 pandemic has placed nursing at the forefront of public attention across the globe and has highlighted the critical role of nursing in healthcare service provision. Advanced practice nursing has been recognized for more than 50 years, but the rate of its growth and development varies significantly across the world. One of the key aims of the Better Health Programme Mexico, which commenced in 2019, was to develop advanced practice nursing in Mexico. The Programme was based on the United Kingdom model, where advanced practice nursing has been in place-though not subject to statutory regulation-for more than 40 years. The aim of this article is to compare the frameworks that underpin advanced practice nursing in the United Kingdom and in Mexico. In the present article, current practice in both countries was researched, and the structure, systems, and processes relating to nursing regulation and the frameworks to support advanced practice nursing were examined. A gap analysis report undertaken as part of the Better Health Programme identified challenges in developing advanced practice nursing in Mexico and the United Kingdom and highlighted the need for stakeholders to agree on an approach toward a rigorous regulatory framework in both settings. In summary, this article highlights the issues facing nurses and regulators in both countries in terms of advanced practice nursing and identifies strategies that can be used to strengthen the advanced practice nurse role.

Sociodemographic and work environment correlates of missed nursing care at highly specialized hospitals in Mexico: A cross-sectional study.

BACKGROUND: Despite its direct relevance to quality of care, little is known about missed nursing care or its sociodemographic and work environment correlates at highly specialized hospitals in low- and middle-income countries. OBJECTIVE: To analyze the frequency of missed nursing care among Mexican nursing professionals, and to assess its associated sociodemographic and labor-related predictors. DESIGN AND METHODS: A cross-sectional, observational study based on data collected from 315 nursing professionals in 11 highly specialized public hospitals in Mexico. We assessed missed nursing care both as a total figure and according to the four dimensions of the MISSCARE inventory. We estimated its sociodemographic and work-related predictors using fractional logistic analysis. RESULTS: The global score for missed nursing care was 15.21%: 7.94% concerned individual needs, 9.37% discharge planning and patient education, 18.10% basic care, and 1.59% care under continuous assessment. The odds of engaging in missed nursing care increased with age and were higher among women and night-shift workers. In contrast, they decreased among nursing professionals who were satisfied with their jobs, and among those working in suitable environments. CONCLUSIONS: Missed nursing care in highly specialized public hospitals is associated with the sociodemographic characteristics and labor-related conditions -including the work environments- of the nurses. Given its impact on both health-care users and institutions, further research on the subject is urgently needed. It is essential to improve the design, implementation and evaluation of comprehensive strategies aimed at reducing the frequency of missed nursing care and achieving universal health coverage.

Labor Market Participation of Bachelor's Degree Prepared Nurses in Mexico: Lessons for Capacity Building.

BACKGROUND: Mexico has learned much from its five decades educating nurses, moving from nurses educated mostly at the technical degree level, to bachelor's degree prepared nurses educated in universities. Several salient lessons have emerged that may prove relevant for other countries seeking to increase their numbers of bachelors prepared nurses. This paper analyzes twenty years of nursing labor market data to highlight where significant social and policy changes helped facilitate increased production of bachelor's degree educated nurses in Mexico. METHODS: We conducted a two-stages analysis, starting with a descriptive stage and followed by a repeated cross-sectional analysis using data sources generated by the Secretariat of Health and the National Institute of Geography and Statistics. Data from the 2005 to 2019 period were analyzed for trends in production patterns and significant relationships in the labor market. RESULTS: Among Mexican nursing graduates, technical and bachelor nurses compete for employment in healthcare institutions. The public sector has greater success in hiring bachelors prepared nurses, but this varies by type of public sector institution. Technical degree nurses have higher underemployment rates and less job security overall. Private hospitals mainly hire technical degree nurses. The Mexican government not been able to properly regulate neither the production of new graduates nor the accreditation of schools, let alone to align roles according to the graduate's level of education. CONCLUSIONS: The success of Mexico in the twenty-first century shows that middle-income countries can increase the production and both private and public sector employment opportunities for nurses educated at both the technical and bachelor's degree level however, labor market challenges persist. The central lesson for other countries is that policies must be revised in order to optimize the use of a more educated nursing workforce.

Distance learning and patient safety: Report and evaluation of an online patient safety course / Educación a distancia y seguridad del paciente: informe y evaluación de un curso en línea sobre seguridad del paciente / Aprendizagem à distância e segurança do paciente: descrição e avaliação de um curso online sobre segurança do paciente

ABSTRACT Patient safety is a critical topic in health care globally, with implications for nurses, physicians, administrators, and most importantly, patients and their well-being. Online distance learning (ODL) is widely accepted among most disciplines in higher education and has been used to promote patient safety knowledge among health care students and professionals in diverse contexts. This article reports on an online Nursing and Patient Safety course developed in 2012 by the University of Miami School of Nursing and Health Studies in conjunction with the Pan American Health Organization and the International Network for Nursing and Patient Safety. The study's objectives are to describe the implementation of an international ODL program to enhance patient safety knowledge in nurses and nursing students, and to examine the participants' assessments of this online approach as an effective learning tool. Most participants who completed the Nursing and Patient Safety ODL course reported being satisfied with the course content and experience, and demonstrated increased knowledge on patient safety, as measured by post-module quizzes and self-report. Limitations of the study include the lack of a comparison group, disparity in the number of participants across the course's language formats (English, Portuguese, Spanish), and the large number of participants who registered for but did not complete the course. Future research should identify obstacles to course completion, explore participants' awareness of patient safety issues and perceived need for more instruction, and look at ways to disseminate the course to the broadest international population of nurses and nursing students.(AU)

RESUMEN La seguridad del paciente es un tema fundamental en la atención de la salud a nivel mundial, con repercusiones para los enfermeros, médicos, administradores y, lo que es más importante, para los pacientes y su bienestar. La educación a distancia en línea está ampliamente aceptada en la mayoría de las disciplinas de enseñanza superior y se ha empleado para difundir los conocimientos en materia de seguridad del paciente a los estudiantes de atención de salud y los profesionales en diversos contextos. En este artículo se informa sobre el curso en línea de enfermería y seguridad del paciente creado en el 2012 por la facultad de enfermería y estudios de salud de la Universidad de Miami, conjuntamente con la Organización Panamericana de la Salud y la Red Internacional de Enfermería y Seguridad del Paciente. Los objetivos del estudio son describir la ejecución de un programa internacional de educación a distancia en línea para mejorar el conocimiento sobre la seguridad del paciente de los enfermeros y los estudiantes de enfermería, y examinar las evaluaciones de los participantes sobre este enfoque en línea como herramienta eficaz de aprendizaje. La mayoría de los participantes en este curso afirmó sentirse satisfecho con su contenido y experiencia, y demostró un mayor conocimiento sobre la seguridad del paciente, de acuerdo con las mediciones de las encuestas posteriores al módulo y la autoevaluación. Entre las limitaciones del estudio se aprecia la falta de un grupo de comparación, una disparidad en el número de participantes entre las diferentes versiones lingüísticas del curso (español, inglés y portugués) y el gran número de participantes que se inscribieron sin llegar a finalizar el curso. Las futuras investigaciones deberán indicar cuáles son los obstáculos para la finalización del curso, explorar la concienciación de los participantes en temas relativos a la seguridad del paciente y las necesidades que perciben de una instrucción más profunda, así como considerar modos de mayor difusión del curso en la comunidad internacional de enfermeros y estudiantes de enfermería.(AU)

RESUMO A segurança do paciente é um tema fundamental para a assistência de saúde em todo o mundo, com implicações para enfermeiros, médicos, administradores e, mais importante ainda, para os pacientes e o seu bem-estar. A educação à distância online (EDO) conta com grande aceitação na maioria das disciplinas do ensino superior e tem sido utilizada para transmitir conhecimentos sobre segurança do paciente a estudantes e profissionais da saúde em diversos contextos. Este artigo descreve um curso online de Enfermagem e Segurança do Paciente desenvolvido em 2012 pela Faculdade de Enfermagem e Estudos da Saúde da Universidade de Miami, em conjunto com a Organização Pan-Americana da Saúde e a Rede Internacional de Enfermagem e Segurança do Paciente. Os objetivos do estudo são descrever a implementação de um programa internacional de EDO para melhorar os conhecimentos de enfermeiros e estudantes de enfermagem sobre segurança do paciente e examinar a forma como os participantes avaliaram a eficácia desta abordagem online como uma ferramenta de aprendizagem. Em sua maioria, os participantes que completaram o curso online de Enfermagem e Segurança do Paciente afirmaram ter tido uma boa experiência com o curso e estar satisfeitos com o seu conteúdo; além disso, demonstraram maiores conhecimentos sobre segurança do paciente, medidos por questionários aplicados após os módulos e pela autoavaliação. As limitações deste estudo incluem a falta de um grupo de comparação, a disparidade no número de participantes nos diferentes formatos do curso (inglês, português, espanhol) e o grande número de participantes que se inscreveram mas não completaram o curso. A pesquisa futura deve identificar os obstáculos à conclusão do curso, explorar a conscientização dos participantes sobre questões de segurança do paciente e a necessidade de mais instrução e procurar formas de divulgar o curso para uma população internacional mais ampla de enfermeiros e estudantes de enfermagem.(AU)

La Investigación en la Escuela Nacional de Enfermería y Obstetricia ENEO-UNAM. México / Research at the National School of Nursing and Obstetrics ENEO-UNAM. Mexico

Resumen:

Este trabajo permite identificar las acciones estratégicas que la ENEO ha desarrollado durante los últimos años en materia de investigación, su organización en grupos por ejes temáticos, el análisis de su productividad y organización en el marco de las prioridades en salud, educación y enfermería. También se comparte la estrategia definida por la ENEO para la identificación colegiada de las fortalezas y debilidades de los grupos de investigación formalizados hace cinco años y su nivel de avance. El artículo también plantea la reorganización que los grupos han experimentado para contribuir al desarrollo sostenido y de calidad en la investigación institucional.

Inserción laboral, desarrollo profesional y desempeño institucional de las (os) egresadas (os) del Plan Único de Especialización en Enfermería de la ENEO-UNAM: una experiencia de doce años / Labor market integration, professional development, and institutional performance of the graduates from the unique plan of specialization in nursing of the ENEO-UNAM: a 12 year experience

Objetivo: Analizar las características que adopta la Inserción y desempeño laboral así como el Desarrollo profesional de las egresadas(os) del Plan Único de Especialización en Enfermería (PUEE) de la ENEO-UNAM. Marco Teórico. Inserción Laboral es un término usado para referirse al proceso de incorporación de los individuos a la actividad económica. El desarrollo profesional, es el fruto de la carrera, comprende los aspectos que enriquecen a la persona con vistas hacia el logro de metas dentro de la organización. El desempeño institucional incluye acciones o comportamientos de los empleados, relevantes para con los objetivos de la organización medidos en términos de competencias y niveles de contribución. Metodología. Estudio descriptivo y transversal, las variables de la inserción laboral fueron: Centro/institución de trabajo, categoría, antigüedad, salario y funciones principales. Las dimensiones del desarrollo profesional fueron: responsabilidad, autonomía, trabajo en equipo y posicionamiento. Las del desempeño Institucional: características de la Institución empleadora, satisfacción con el desarrollo profesional del egresado, y vinculación con la ENEO. La muestra fue de 417 egresados y trece instituciones encuestadas. Para el Desempeño Institucional se aplicaron 86 cuestionarios, a personal directivo de enfermería tanto de instituciones públicas como privadas. Resultados. La Inserción laboral mostró que la actividad principal desarrollada por los egresados es la atención directa, en Desarrollo Profesional los egresados perciben que la especialidad les habilitó para actuar con responsabilidad, autonomía, y trabajar en equipo, pero en el ámbito laboral el reconocimiento es limitado. El perfil del egresado coincide con lo requerido por las instituciones empleadoras y el desempeño es percibido como bueno.

Objective: Analyze the characteristics of the processes of labor market integration and performance, as well as professional development in the graduates from the Unique Plan of Specialization in Nursing (UPSN) of the ENEO-UNAM. Theoretical Frame: Labor market integration is a term commonly used to refer the process of incorporating individuals into the economic activity. Professional development is the fruit of the career and includes the aspects which enrich the person towards the achievement of goals within the organization. Institutional development includes the actions or behaviors of the employees which are relevant to the objectives of the organization, and which can be measured in terms of competences and contribution levels. Methodology: This is a basic and descriptive study and the measured variables of labor market integration were; center/institution of work, category, seniority, salary, and principal functions; the dimensions of professional development were; responsibility, autonomy, team-work, and position; and the dimensions of institutional performance were; employer characteristics, satisfaction with the graduate's professional performance, and bonds with the ENEO. The sample included 417 graduates from the UPSN, and 13 institutions. To collect data related to institutional performance, 86 questionnaires were given to the directive nursing staff of both the public and private institutions. Results: labor market integration showed that the graduate's principal activity is direct attention. In relation to professional development, graduates perceive that their specialties enable them to perform with responsibility and autonomy, and to work in teams, but also that the acknowledgement is limited. The graduate's profile fits that required from the employer institutions, with a performance perceived as good.

Hospitales magnéticos para la mejora de la calidad del cuidado / Magnet Hospitals to Improve Quality of Care

Resumen

En las instituciones de salud a nivel nacional existe escasez y una alta rotación de enfermeras, ambas situaciones se atribuyen a la insatisfacción laboral que puede ser causada por el síndrome de Burnout, poco reconocimiento entre pares y de la sociedad, percepción de falta de apoyo para la capacitación y desarrollo profesional, sobrecarga de trabajo en relación a la asignación del número de paciente/enfermera; lo anterior provoca mala calidad en la atención, aumento en los eventos adversos, altos costos en salud y por consiguiente, insatisfacción del usurario. Una estrategia para resolver esta problemática son los Hospitales Magnéticos considerados como aquellos que atraen y retienen a los profesionales de enfermería en las instituciones de salud para brindar cuidados de excelencia a través de ocho elementos magnéticos. Es por ello que en este trabajo se vinculan las ocho fuerzas magnéticas con la trilogía de evaluación de la calidad de Donabedian, destacando los beneficios para el paciente, el profesional de enfermería, la institución y la sociedad. Con ello el lector identificará áreas de oportunidad para su práctica diaria.

Summary

Nationwide there is a shortage and high turnover of nurses in health institutions, both are attributed to job dissatisfaction that can be caused by Burnout syndrome, little recognition among peers and society, perceived lack of support for training and professional development, overburden related to the number of patients per nurse; aforesaid can led to poor quality of care, increase of adverse events, high costs in health care and therefore user dissatisfaction. A strategy for solving this problem are Magnet hospitals considered as those that attract and retain nurses in health institutions to provide excellence in care through eight magnetic elements. That is why this paper links the eight magnetic forces to Donabedian’s trilogy of quality assessment, highlighting the benefits for patient, nursing professionals, the institution and society. With this the reader will identify areas of opportunity in daily practice.

Situación de la investigación en enfermería en Méjico / Situação da pesquisa em enfermagem no Méjico / Situation of the nursing's research in Mexico

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La formación y la práctica social de la profesión de enfermería en México / Formation and social practice of the nursing profession in Mexico

Este artículo plantea los antecedentes históricos y la situación actual de la formación y práctica de la enfermería en México; hace énfasis enla reconceptualización que la Escuela Nacional de Enfermería y Obstetricia -ENEO- de la Universidad Nacional Autónoma de México -UNAM- ha venido realizando sobre la enfermería profesional y la incorporación de estos elementos al curriculo. Presenta algunas de las características de la práctica de enfermería y su campo laboral así como los recursos humanos existentes en las principales instituciones de México. El propósito es describir la práctica social de la profesión de enfermería en México y la orientación curricular al interior de la ENEO-UNAM como resultado de un enfoque disciplinario hacia el cuidado de enfermería.

Informe final del taller internacional de gerencia en enfermería en los servicios de salud / Final report of the international workshop of nursing management in the health services

A nivel temático, este taller abordó principalmente: la gerencia institucional ubicada en el contexto en que se desarrolla (modernización del Estado, la reforma de la administración pública, el enfoque gerencial con sus potencialidades y limitaciones, su ámbito de competencia y por último sus funciones). En el tema de la gerencia en Enfermería participaron enfermeras de Canadá, Colombia y México, las que presentaron un panorama general de las reformas en los sistemas de salud y el impacto en la práctica de la enfermería ante los proyectos de reforma institucional