Nursing Policy Dialogue in Uruguay: Advances and Challenges 2021–2025

1. Introduction

Strengthening health systems for universal coverage requires the development of their human resources, with nursing being an essential component. Nurses constitute the largest professional group in health systems worldwide, and their adequate training, distribution, and working conditions, as well as the professional practice environments where they work, are key to quality of care, health outcomes, and professional well-being [1,2,3].

In Uruguay, as in other countries in the region, there is a significant deficit of professional nurses, with territorial imbalances and scarce development opportunities [3,4]. This situation motivated, in 2021, the beginning of the Nursing Policy Dialogue in Uruguay (NPDU), promoted by the Pan American Health Organization (PAHO) and supported by the Ministry of Public Health, with active participation from the Universidad de la República and Universidad Católica del Uruguay, bringing together more than 700 participants in four working groups [5].

The process culminated in a National Nursing Development Plan with objectives to reduce the professional deficit, improve staffing and working conditions, and expand the role through postgraduate training and interprofessional practices [5,6]. The plan aligned with PAHO/WHO strategic directions for universal health access, recognizing nursing personnel as a pillar of equitable and sustainable health systems [7].

Four years after its initiation, it is key to understand advances, obstacles, and next steps to consolidate objectives. This analysis is particularly relevant in a regional context that demands stronger health systems and ensuring sufficient and competent human resources [8,9]. Insights from committed professionals are essential to designing policies that contribute to achieving national health goals.

In this regard, the following research questions guided this study: How was the nursing policy dialogue process perceived in the country? What have been the advances after this time has passed? What transformations and challenges, from the historical experience and tradition, may be significant in the current scenario that national Nursing is experiencing?

Therefore, this study aims to analyze the advances and challenges of the NPDU process initiated in 2021, based on the experiences of nurses who actively participated in its process and follow-up of the agreements.

2. Materials and Methods

2.1. Design

A qualitative exploratory study was conducted, guided by the dialectical hermeneutics approach. This perspective assumes that knowledge is constructed in the subject-world interaction, and that meanings are not given but interpreted. This approach is particularly relevant for understanding complex social phenomena such as professional leadership trajectories and processes of collective transformation. Dialectical hermeneutics offers tools to analyze the interpretations that people construct from their historicity, situated experience, and active participation in concrete processes. In addition to allowing understanding of phenomena from lived experience and tradition, this approach incorporates a critical dimension that interprets tensions and contradictions in narratives of change. This combination of understanding and critique makes it an especially pertinent approach for studying the advances, difficulties, and future projections of NPDU, from the voices of those who have had an active role in its development and consolidation [10,11,12,13].

2.2. Participants and Sampling

The selection of participants was carried out through theoretical-purposive sampling, oriented to capture significant, diverse, and relevant experiences in relation to the phenomenon under study. Twelve nurses who had participated directly in the NPDU in 2021 and who, since then, had assumed leadership roles in their respective areas were included. To ensure a heterogeneous and representative sample of the professional spectrum, informants from different sectors were included: academic (n=3), health management (n=4), clinical practice (n=3), and professional organizations (n=2).

The inclusion criteria were: a) having actively participated in the NPDU webinars of 2021; b) actively practicing the profession at the time of the study; and c) providing consent to participate. Professionals who did not directly participate in the dialogue process or who were retired or disconnected from their professional practice were excluded. Theoretical saturation was reached when the information collected began to repeat itself and no new analytical categories emerged, which helped define the final sample size according to criteria of exhaustiveness and relevance [13,14].

2.3. Procedure

Following protocol approval by the ethics committee, potential participants were contacted personally via email or direct telephone communication, explaining objectives, inclusion criteria, and ethical principles. Those who agreed to participate received the informed consent form, which was clarified and signed prior to the interview. Date, time, and place were arranged individually, prioritizing private and comfortable settings. Interviews were conducted between April and May 2025.

During the meetings, a respectful and receptive attitude was maintained, promoting free participation, without interruptions or directions, and fostering a relationship of horizontality between interviewer and interviewee. The aim was to favor a space for subjective reflection, validating subjective experiences as a legitimate source of knowledge. The interviews lasted between 30 and 45 minutes and were recorded with the explicit authorization of each participant. Each transcription was identified with an alphanumeric code (E1-E12) to preserve the anonymity of the informants.

2.4. Data Collection

For data collection, the in-depth interview technique was used, chosen for its capacity to favor the detailed, contextualized, and reflective account of lived experience. A semi-structured guide was used with five open questions focused on: 1) perceptions about the NPDU process, 2) follow-up of the strategic plan, 3) perceived advances, 4) future projections, and 5) analysis of the current context. The questions were defined in such a way as to extract the best data, taking care that they did not have biases of any kind. The guide was validated internally within the research team to ensure its coherence with the study objectives and its adequacy to the theoretical approach.

2.5. Data Analysis

Content analysis was employed, following the sequence of organization, classification, and final analysis [15], which studies data in context and identifies meaning units. The analytical process included: 1) reading of transcriptions; 2) coding of significant units; 3) grouping into categories; and 4) construction of analytical categories. The analytical process was carried out by two researchers collaboratively, through discussions that generated consensus. This theoretical and researcher triangulation was used as an internal validation strategy, ensuring the consistency and depth of the analysis, as well as fidelity to the informants’ narratives.

2.6. Ethical Considerations

The study was approved by the Research Ethics Committee of Universidad Católica del Uruguay (Ref. SOLCOMET-177). Free, informed, and written consent was guaranteed for all participants, who were previously informed about the objectives, scope, risks, and benefits of the study, as well as their right to withdraw at any time without consequences. Confidentiality was protected through the coding of interviews and secure storage of records. The data collected were used exclusively for academic and research purposes and were not shared with third parties.

3. Results

The exhaustive analysis of the interviews allowed significant aspects of the discourses to emerge in relation to the fruits of the NPDU. The categories constructed were partial achievements under critical scrutiny, need to design policies, challenging collective construction, local networks of professional action, representation and emerging leaderships.

Regarding the construction of the category of partial achievements under critical scrutiny, it addresses how nurses evaluate some results emerging from the process, recognizing achievements but questioning timelines and implementation. This is visualized in some discourses:

[...] The policy dialogue was an excellent tool that produced concrete proposals and gave support to the national Nursing plan, there were advances in generating documents such as the staffing one, but there was a lack of implementation, we stayed on paper... that has been historical for us... (E1).

[...] I remember everything that was discussed in the dialogue, and that was very valuable, that moment was fantastic where many people from all over were building. Then there were documents and I think a report was published... yes, there was a published report. It needed to move faster with the advances... (E5).

[...] Things were achieved, we must remember that the issue of regulating staffing was not on the agenda and people started talking about it and a key document was submitted. But in other cases, in some way it was more of the same, many very rich discussions, but where are the concrete actions? (E7).

In line with the above, the category need to design policies emerges as a solution, related to the previous category, so that advances are more substantial and maintained in the medium and long term. This category is constructed based on discourses such as:

[...] The key is to get off paper and promote the design of Nursing human resource policies that sustain long-term projects, otherwise it’s impossible, otherwise we’re going to keep over-diagnosing and nothing more. (E1).

[...] Many years have passed and we continue waiting for a state policy that ensures a plan. If there is no written policy with a budget, we’re going to remain the same (E7).

[...] The policy dialogue was a fundamental tool for us to wake up, not because work hadn’t been done, but because it allowed people from all over to integrate, even people who weren’t nurses, but they told us how they saw us... (E10).

In turn, the category of challenging collective construction is defined as a result of the NPDU, as a fruit of the process that brought nurses together in collective agreements. It emerges from participations such as:

[...] For me the most valuable thing, beyond whether the results appear or not, was how we organized collectively, with people from here and there, from all over, that’s the strength of the collective... (E4).

[...] And that’s where Nursing 2030 emerged... well, I don’t know if it emerged there, but Nursing 2030 is something similar, that previous experience was useful, because Nursing 2030 is based on the collective participation of everyone... (E8).

[...] That was needed, we needed to have platforms for advocacy, or rather for proposals that were collective, not personal or not from the public or private sector, that of going together with ideas from everyone and from there building things that we all agree on, then there will be things we don’t agree on and we must respect that... (E10).

Along these lines, in the category local networks of professional action, subjects identify as valuable the fact that the NPDU, and the subsequent platforms that emerged, have generated networks of nurses who, from their places of professional experience, promote dialogue and collective participation actions. Discourses are visualized such as:

[...] I couldn’t believe it when I saw colleagues from all over the country joining, but look, they were from everywhere, I couldn’t believe it, every day a new nurse appeared from a remote department sometimes... that gave a lot of vision of the whole country... (E7).

[...] There were colleagues who went to talk to mayors or aldermen and explained the Nursing 2030 proposals to them, I think everyone at the same time, like that, it had never happened... (E9).

[...] The fact that local groups of nurses were formed was a success, I wish we could continue working like this in networks, it’s a great strength... (E12).

Finally, the category representation and emerging leaderships is one of the most significant results, with new leaders emerging who learn negotiation strategies and deploy actions in the territory. A renewal of leaderships is perceived, with new figures appearing in different parts of the country:

[...] Leaderships are important, but if they are always the same they cease to make sense... policy dialogue, for me, made more people realize the importance of politics, in the good sense, of going, talking, dialoguing, relating to those who hold the reins... new leaders emerged who can transform realities... (E4).

[...] There were people I didn’t even know, but I saw them moving naturally... they went smoothly to present the platform to people in their city or department and achieved important things, at least they became known and stayed in contact with decision-makers... (E8).

[...] I think we are in a very good historical stage, there are possibilities to consolidate the work of many years, there are transformations to come... (E12).

4. Discussion

Authors should discuss the results and how they can be interpreted from the perspective of previous studies and of the working hypotheses. The findings and their implications should be discussed in the broadest context possible. Future research directions may also be highlighted.

After four years since the NPDU, progress has continued and the process has been monitored. This study provides input on the emerging experiences from this process that can be replicable in other countries where these types of projects are carried out. The NPDU made it possible to highlight and strengthen organizational dynamics that previously existed in a fragmented manner, providing an opportunity for political articulation and projection. From the active participation of over 700 nurses nationwide in 2021, new forms of leadership, organization, and territorial representation emerged [5].

From this study, the category of partial achievements under critical scrutiny has emerged, which reflects the perception of nurses participating in the NPDU process. While they recognized certain advances, such as placing the issue on the public agenda, strengthening professional leadership, opening channels of dialogue with political actors, and producing technical documents, they also questioned the depth, sustainability, and concreteness of these achievements. Some participants perceived delays in implementing key proposals, as well as institutional resistance to adopting structural changes. Addressing these issues will require the consolidation of a roadmap, as evidenced by previous studies [16]. This will enhance reflective and analytical thinking among stakeholders, particularly decision-makers. It is also worth mentioning that, despite the existing tensions and obstacles, there is evidence that health policy outcomes have been achieved when nurses are actively involved [17]. This study’s hermeneutic perspective highlights the value of dialogue as a tool for participation and engagement with others, enabling strategies to overcome barriers [18].

In this sense, the need for policy design emerges as fundamental for sustaining concrete and dynamic implementation plans. Despite the advances achieved by the NPDU, participants still perceived regulatory gaps that limit the consolidation of deep and sustainable transformations for the profession. In line with this, the WHO has urged stakeholders to commit to creating policies that support nursing in order to achieve universal health coverage and the Sustainable Development Goals [19].

The interviewed nurses identified that many of the topics discussed and agreed upon during the dialogue, such as improving the work environment, developing human resources to a professional level and strengthening the role of the licensed nurse, had not yet been translated into concrete public policies with financing, planning and evaluation mechanisms in place. This category reveals an explicit demand to progress from dialogue to the institutionalisation of change by designing and implementing specific policies. The participants, in turn, express their willingness to contribute to the technical and political design of such policies as active stakeholders, in line with international studies [17,20,21].

Similarly, this category acknowledges that, while the dialogue process is valuable, it is merely a starting point for a more structural stage. At this stage, political decisions are required to convert agreed proposals into programme, regulatory and budgetary actions.

This involvement, which followed the NPDU in stages, was consolidated into organisational structures, resulting in a challenging collective construction. Participating nurses describe this process as valuable but complex, involving dilemmas and conflicts about the direction of the profession. However, this different vision of the processes enriched the path towards consensual ideas by taking into account the particularities of each group, including factors such as diversity of trajectories, hierarchical roles and generational differences. The coordinated action of these actors, as well as others in the system, has been called for by the WHO as part of collective synergies to implement concrete nursing plans [22].

The challenging nature of this collective construction does not detract from the value of the process; on the contrary, it enriches it by demonstrating that achieving consensus involves managing legitimate tensions and professional diversity. One concrete action following the NPDU was the formation of the Nursing 2030 group. Although this group was not directly derived from the NPDU, it shares its purposes and objectives. This group emerged organically among committed nurses and functions as a strategic platform to address future challenges and engage in dialogue with the entire political spectrum of the country prior to the electoral period. Nursing 2030 strengthens the connections made during the dialogue and transforms them into a sustained network with the capacity to analyse and advocate. The group’s strength lies in its combination of technical training, practical experience, political leadership and prospective vision, which positions nursing as a proactive force within the healthcare system. Studies show that organised nurses are key to reaching consensus and achieving public policies [23]. Thus, nurses cease to be mere demanders and become proactive actors with the technical and political capacity to influence the direction of the collective.

Along these lines, the category of representation and emerging leadership emerges as one of the most significant and transformative results of the NPDU process. Throughout this process, many nurses who had not previously occupied visible spaces of participation began to assume leadership and collective articulation roles at the national and local levels by forming local networks of professional action. From a hermeneutic approach, the dialogue process is an excellent tool for territorial dialogue and progress in reaching a consensus with decision-makers [24]. This phenomenon indicates that the dialogue generated results not only in terms of technical proposals but also strengthened individual and collective political capacities. Participants relate how some colleagues began participating in different types of commissions, demonstrating greater commitment in union spaces, and engaging in meetings with decision-makers, academic activities, and grassroots initiatives in their territories. Some barriers and obstacles described in the literature were overcome in the process [25].

The dialogue process functioned as an empowerment mechanism that fostered new forms of participation and renewed professional leadership—something fundamental to long-term sustainability. These processes enable interaction, contextualized understanding, and collective debate [26].

Emerging leaders contribute a critical and proactive outlook, energizing nursing in Uruguay and consolidating more diverse, active, and aligned professional representation to address current and future challenges. The key challenge now is sustaining proactive action, maintaining momentum, developing medium- and long-term policies, and ensuring their implementation. This aligns with the State of the World’s Nursing Report’s recommendations [19]. While all stakeholders have a role to play, nurses are central figures. Strengthening emerging leadership from various sectors, including education and training, is essential as we approach 2030 [28].

Recent reports urge governments, educators, employers, associations, and regulators to consistently invest in nursing education, employment, leadership, and well-being. These investments should focus on equity and sustainability in order to advance toward universal health coverage and the Sustainable Development Goals [19]. Collective action is essential for overcoming the challenges of the profession. As demonstrated in previous studies, well-designed activities can politically empower nursing by fostering leadership, representation, and participation in health policy [28]. Our findings on emerging leadership and collective construction are consistent with this, demonstrating how practical experience transforms technical knowledge into political action.

5. Conclusions

The NPDU process, which began in 2021, was a turning point for the professional collective. It opened spaces for participation, strengthened leadership, and articulated organizational dynamics, especially through new platforms such as Nursing 2030. Through analyzing participating nurses’ experiences, this study recognized both the achievements and the persistent challenges.

The study’s key findings point to categories that provide a thorough evaluation of the process. These categories highlight significant achievements, although these achievements are limited in their implementation. They also emphasize the need to design public policies that institutionalize the agreed-upon principles. Additionally, the categories point to the emergence of diverse collective construction and the rise of leaderships and forms of representation with strong territorial anchoring.

Thus, the NPDU marked the beginning of a path requiring continuity, political will, and institutional commitment to translate dialogue into sustainable, concrete public policies that address national and international challenges of the nursing profession.