Governance, Accountability and Professional Regulation in Nursing: Lessons From the Spanish Experience

Professional regulatory bodies serve as the cornerstone of nursing practice standards, shaping not only clinical practice but also workforce conditions and, ultimately, patient care outcomes. Despite the existence of recommended standards for nursing governance (International Council of Nurses 2014), there remains a limited understanding of how these standards are implemented across different cultural and national contexts. As Browne et al. (2021) note, healthcare professional regulation represents a relatively undeveloped field of academic inquiry, particularly in terms of comparative international analysis. This commentary uses recent developments in Spain as a case study to promote critical reflection on nursing governance structures internationally and to encourage scholarly examination of accountability mechanisms within the profession. For nearly three decades until 2017, the Spanish nursing profession's national regulatory body, Consejo General de Enfermería (CGE), was led by Máximo González Jurado. The CGE also functions as the nursing national professional association, with mandatory membership through regional chapters. During this extended period of leadership, González Jurado became a prominent figure in global nursing, developing professional relationships and mentoring international nursing leaders. This concentration of power and influence within a single leadership figure presents an opportunity to examine the potential implications of long-term governance structures on professional regulatory outcomes. According to recent reports in Spanish media, legal proceedings have resulted in a prison sentence for González Jurado related to allegations of mismanagement and misappropriation of institutional funds (Urreiztieta 2024). Separately, court documents from another ongoing legal investigation as reported by Cinco Días and Morcillo (2023), document the alleged use of CGE-linked companies for personal and family expenses totaling 20 million Euros. These developments raise important questions about accountability mechanisms and financial oversight within professional regulatory bodies—questions that extend well beyond the Spanish context to nursing governance worldwide. What appears particularly noteworthy from a scholarly perspective is that, despite these reported judicial findings against a recipient of nursing's prestigious Christiane Reimann Prize, international nursing organizations have not publicly addressed these developments or reconsidered previously granted honors. This silence prompts critical questions about how the nursing profession globally manages accountability and integrity in its leadership structures and invites scholarly examination of how professional recognition and awards are monitored after they are bestowed. The governance issues reported in the Spanish case appear to extend beyond financial management. According to multiple journalistic accounts, professionals who questioned governance practices during this period reportedly faced significant professional challenges. For example, Spanish media sources have documented cases such as those of Juan Hernández Yáñez (Valerio 2016) and Alda Recas (Galaup 2017), who allegedly encountered judicial and administrative actions after raising concerns about organizational conduct. These reports invite critical reflection on how regulatory bodies balance their disciplinary roles with the protection of those who voice governance concerns. This tension between professional discipline and whistleblower protection represents a significant area for nursing scholarship with implications for transparency in healthcare organizations globally. While research interest in whistleblowing within nursing and healthcare organizations has grown in recent decades (Ibrahim 2024), the specific study of consequences faced by those who report concerns about the very regulatory organizations designed to protect whistleblowers remains largely underexplored. How can the profession develop governance structures that both maintain professional standards and allow for internal critique and reform? This critical question warrants greater scholarly attention in nursing literature. The governance challenges reported in Spain do not appear limited to a single individual. According to Spanish news sources, the current CGE president, Florentino Pérez Raya (González Jurado's close collaborator who succeeded him), is reportedly under ongoing judicial investigation for potential misuse of organizational funds (Hernández 2021). These developments raise questions about our understanding of governance structures, financial oversight, and the management of professional membership contributions in regulatory bodies internationally, suggesting that further research might contribute valuable insights to this relatively unexplored area. Examining institutional oversight mechanisms presents complex research challenges. Key questions arise regarding how organizational structures support or hinder effective governance, and what responsibilities board members and associates hold in these oversight roles. The fact that these investigations directly or indirectly involve leaders who also occupy prominent positions in national and international nursing organizations, including the ICN, points to the need for comparative research on governance standards across nursing bodies. A particularly relevant area for nursing workforce research is the potential relationship between regulatory body effectiveness and workforce outcomes. After three decades under relatively stable leadership, Spain continues to report one of Europe's lowest nurse-to-population ratios at 6.3 per 1000, significantly below European Union averages (OECD 2022). The country faces documented challenges including nursing unemployment, precarious employment conditions, suboptimal work environments, reported workplace harassment (Paniello-Castillo et al. 2023), and nurse migration (Galbany-Estragués et al. 2022), even as the profession maintains a positive international image. These indicators highlight the imperative that we examine possible associations between regulatory effectiveness and health human resources outcomes. Our understanding of how the abuse of entrusted power for private gain negatively affects the healthcare sector in general continues to grow (Glynn 2022), yet the specific direct causal relationships between regulatory governance and adverse workforce outcomes cannot be established without deep and evidence-based analysis. A more robust understanding of these relationships could have significant implications for global health systems (Koller et al. 2020). The moral impact on frontline nurses of such governance failures should not be underestimated. When nurses witness or perceive corruption within the very institutions designed to protect their profession and the public, it can profoundly undermine professional morale and create a pervasive sense of helplessness. As Transparency International (2019) notes, corruption within healthcare systems not only diverts resources but erodes trust and professional commitment. For bedside nurses already struggling with challenging work conditions, the perception that their professional bodies are failing in ethical governance can exacerbate moral distress and contribute to burnout and attrition. Despite its potential impact on workforce sustainability and patient care quality, this psychological dimension of regulatory governance impact has received insufficient scholarly attention. The Spanish experience raises several important questions: To what extent should regulatory bodies be held accountable for workforce conditions? What mechanisms exist for nurses to provide feedback on regulatory effectiveness? How can the profession ensure that regulatory bodies remain focused on their core missions of public protection and professional advancement rather than becoming entrenched bureaucracies? Moving from words to action, several organizations including the European Union (Sommersguter-Reichmann and Reichmann 2024) and the World Health Organization (2023) have launched programs to combat corruption in the healthcare sector. We can learn from these experiences and adapt some recommendations for regulatory bodies. Several approaches might strengthen nursing governance globally. First, effective interventions may involve establishing formal collaboration with an external, independent oversight body responsible for the identification and enforcement of anticorruption protocols within nursing governance institutions (Gaitonde et al. 2016). This could include, for example, protocols for reviewing and potentially revoking honors and awards when recipients are shown through established processes to have demonstrated serious departures from professional or ethical standards. Such protocols would reinforce the profession's commitment to integrity at all levels. Transparent financial disclosure practices and independent auditing should become standard across nursing organizations. While many organizations already implement such practices, creating international standards for financial transparency in nursing governance could strengthen accountability. Establishing protected channels for raising governance questions or concerns without fear of professional repercussions would also enhance internal accountability. In addition, nursing regulatory bodies could benefit from implementing term limits for leadership positions, preventing the consolidation of power that might facilitate governance failures. The profession must balance its focus on leadership development with equal attention to cultivating “effective followership.” As Kelley (1988) argues, effective followers who question, challenge, and hold leaders accountable are essential to healthy organizational cultures. Despite decades of emphasis on nursing leadership, there has been remarkably little investment in educating nurses to become effective, ethical, and courageous followers (Honan et al. 2022). Professional organizations and educational institutions could develop specific curricula internationally focused on ethical followership, including skills in constructive dissent, ethical whistleblowing, and collective action when governance concerns arise. This rebalancing of the leadership-followership dynamic could serve as a crucial check on the consolidation of power that enables governance failures. Finally, mirroring developments in the broader healthcare sector (Lu et al. 2020), fostering a culture that promotes open dialogue about corruption in nursing governance organizations instead of “washing the dirty linen inside” is fundamental. Only through such transparency will we be able to develop meaningful solutions to a problem that in some countries seems to have become structural. The nursing profession faces significant challenges globally, from workforce shortages to evolving practice environments. Effective, ethical governance of regulatory bodies represents a critical foundation for addressing these challenges. Clearly, scholarly examination of the relationship between regulatory governance and workforce outcomes could better inform our capacity to ensure integrity of direction. The reported experiences from Spain offer an opportunity to call for critical reflection on governance structures and accountability mechanisms within nursing worldwide. By examining this case study through a scholarly lens rather than simply dismissing it as an isolated incident, the profession stands to learn more about fostering the kinds of robust approaches to governance that optimize nursing's core mission of providing high-quality care to our patients and health for the populations we serve. The nursing profession worldwide is founded on ethical principles that should permeate all professional activities, including governance. The profession's commitment to integrity must extend from individual clinical practice to the highest levels of professional governance if nursing is to fulfill its potential as a force for positive change in healthcare systems worldwide. The author has nothing to report. The author declares no conflicts of interest. The author has nothing to report.