Readiness of Polish palliative care nurses to expand authority for independent nurse prescribing (INP)

Introduction

The United Nations Agenda for Sustainable Development highlights well-being and good health as the key priorities, in line with the World Health Organization (WHO) strategy. Achieving these goals requires improved access to healthcare services, which is not possible without well-educated, motivated nurses, working to the full extent of their competencies and scope of practice.
According to the WHO, competence refers to the ability to apply knowledge, skills, and attitudes effectively in professional practice. Competencies encompass specific knowledge, skills, and attitudes required, while attitude reflects a person’s values, beliefs, and feelings, which influence behavior and task performance [1].
In Poland, a palliative care nurse is defined by the Ministry of Health as a nurse who has completed either the Fundamentals of Palliative Care course (for vocational education nurses), or a qualification course in palliative care nursing, or holds title of specialist palliative care nurse (SPCN). The first 40 graduates of the palliative care nursing specialty completed their training in 2006. As of the end of 2024, there are approximately 7,432 palliative care nurses in Poland, including 3,517 with the title of palliative nurse specialist [2]. However, only 1,781 of these specialists are actively practicing, representing 24% of all nurses providing palliative care services.
Palliative care nurses work in inpatient settings (hospices, palliative medicine units), home care (home hospices, home care teams), and outpatient clinics. In home care, nurses are often the first point of contact, providing services at least twice a week per patient, compared with physicians, who are required to visit the patient twice a month. Despite this, a 2024 regulation by the President of Poland’s National Health Fund [3] mandates that the first patient visit must be conducted by a physician, restricting nurses’ autonomy. This constraint is linked to the limited prescribing authority of nurses, who currently cannot prescribe drugs from the third step of the WHO analgesic ladder or certain adjuvant medications.
Independent nurse prescribing is expanding globally. Between 2010 and 2016, eleven countries introduced or broadened nurses’ prescriptive authority [4], in line with the WHO Nursing and Midwifery Strategy [5] and the Universal Health Coverage framework [6]. In Poland, nurses were granted independent prescribing rights in 2016, within a strictly defined scope, supported by targeted training. Palliative care nurses, along with other nursing specialists, gained access to a limited list of specific active substances [7], expanded in June 2024 [8]. These include selected analgesics, antiemetics, antibiotics, and medical devices relevant to palliative care (Appendix 1).
The complex symptom burden of palliative care patients, including severe pain, dyspnea, anxiety, depression, appetite loss, pruritus, gastrointestinal disturbances, and oedema, requires timely pharmacological interventions. However, the current scope of nurses’ prescribing authority is insufficient to meet these needs, hindering person-centered care, and contributing to professional frustration and attrition [9].
International evidence suggests that expanding prescribing rights in palliative care can benefit patients, healthcare systems, and payers [10, 11]. The International Council of Nurses and global health policy frameworks recommend the implementation of advanced practice nursing (APN), with prescribing authority as one of its core pillars [6, 12, 13]. Despite investments in training, only 7% of eligible nurses in Poland exercised their expanded prescribing rights in 2022 [14].
This study was therefore undertaken to explore the attitudes of palliative care nurses, particularly those in home care, where the scope of practice is most autonomous towards expanding their authority to include independent prescribing.

Material and methods

The study was conducted in two main stages. Stage 1. Literature review: A targeted search was performed in PubMed, Medline, CINAHL Ultimate, Academic Search Ultimate, Health Source: Nursing/Academic Edition, Health Source: Consumer Edition, and EBSCO databases. The search strategy used key words, such as “independent”, “nurse prescribing”, and “palliative care”. The aim of this stage was to identify existing evidence and regulatory frameworks related to nurse prescribing in palliative care, and to inform the development of the research tool. Stage 2. Survey: It was conducted between January and April 2023. Study population comprised registered nurses providing palliative care in Poland, including those working in inpatient hospices, palliative medicine units, home hospice teams, and outpatient palliative care clinics. Based on registry data, approximately 7,432 palliative care nurses are employed in Poland, of whom 1,781 are active palliative specialist nurses (PNS), representing 24% of the entire group. The research sample therefore covered approximately 1.9% of the national population of palliative care nurses. Although its size resulted from voluntary participation and distribution of the survey by regional consultants, it provided valuable insights into the attitudes of this professional group.

Inclusion and exclusion criteria

Inclusion criteria were active registration as a nurse in Poland, current employment in a palliative care setting, and consent to participate in the study. Exclusion criteria were nurses not directly involved in patient care, and incomplete or invalid questionnaire responses.
Provincial consultants in palliative nursing distributed invitations to participate via professional networks. The questionnaire was also shared electronically with palliative care providers nationwide.

Questionnaire development

The survey instrument consisted of 14 closed-ended, multiple-choice questions, divided into four thematic sections:
1. Use of existing prescribing authority by palliative care nurses;
2. Attitudes toward expanding independent prescribing authority;
3. Perceived needs regarding ability to prescribe specific groups of drugs;
4. Perceived barriers and opportunities related to expanding prescribing authority.
The questionnaire was developed based on the literature review, and refined through consultations with an expert in palliative care nursing and health policy specialist. A pilot study was conducted among 10 nurses to assess clarity and relevance, leading to minor adjustments in wording.

Data collection and ethics

Participation was voluntary and anonymous. Respondents provided informed consent electronically before accessing the questionnaire. No personally identifiable information were collected. Since the study was non-interventional in nature nor a medical experiment, under Polish law, formal Bioethics Committee approval was not required. Therefore, this consent was not obtained prior to conducting the survey among nurses.

Variables

Independent variables included education level (BSN, MSN, PhD, PNS), years of professional experience, and workplace setting (home care, inpatient care, other). Dependent variables were current use of prescribing authority, attitudes toward expansion, and perceived needs and barriers.

Statistical analysis

Data were entered into Microsoft Excel 2016 and analyzed using IBM SPSS Statistics version 23.0. Quantitative variables were summarized as counts and percentages, while associations between quantitative variables were tested using chi-square test. A p-value ≤ 0.05 was considered statistically significant.

Results

Literature review findings

The database search identified 13 articles on independent nurse prescribing. After removing one duplicate, nine articles met the inclusion criteria and were included in the review. These findings were conveyed to the development of the survey instrument.

Survey respondents

A total of 144 nurses met the inclusion criteria and completed the survey. Four incorrectly completed questionnaires were rejected.

Use of existing prescribing authority

The results of the study showed that the place of employment and the level of education correlated with the frequency of exercising prescription rights. Nurses employed in home hospice care were significantly more likely to prescribe medications and medical devices than those working in inpatient hospices (Table 1). Nurses with a master’s degree in nursing (MSN) or a doctoral degree (PhD) were significantly more likely to use prescriptive authority than those holding a bachelor’s degree (BSN) or vocational studies. Nursing specialists were more likely to prescribe drugs than nurses without specialization, and those with both an MSN and a palliative care nursing specialization (PNS) were the most likely to prescribe.

Attitudes toward expanding prescribing authority

Most respondents considered the current scope of independent nurse prescribing in palliative care to be inadequate and supported expanding this authority. Significantly more nurses in home care expressed a desire to increase their competence in this area, compared with those in inpatient care (Table 2). Educational level did not significantly influenced attitudes toward expanding the list of drugs available for independent prescribing.

Perceived needs regarding specific drug groups

The level of education and the place of practice had an impact on the perception of the need to extend the right to prescribe medications by authorized nurses. Nurses with both an MSN and PNS were more likely than other respondents to indicate the need for independent prescribing of co-analgesics, spasmolytics, steroids, benzodiazepines, antipsychotics, and diuretics. Antidepressants were the only group of drugs that nurses with BSN or MSN degrees were generally unwilling to prescribe. Nurses in community palliative care teams were more likely than those in inpatient or other settings to support expanding prescribing rights to include strong opioids, co-analgesics, spasmolytics, steroids, and diuretics. Seniority did not generally affected the preferences, except for spasmolytics, which were most frequently selected by the most experienced respondents (Table 3).

Self-assessed competence and barriers

Palliative nurse specialists (PNS) were more likely than non-specialists to feel competent to prescribe an expanded list of medications. They more frequently supported adding benzodiazepines (p = 0.012) and “Z” group hypnotics (p = 0.005) to the list of drugs for independent prescribing. No statistically significant differences were found between specialists and non-specialists regarding strong opioids (Table 4).
The two most frequently cited barriers to expanding prescribing authority were insufficient training and fear of legal liability. Overall, 88.9% of the respondents believed that developing prescribing competence among palliative care nurses would improve the quality of patient care.

Discussion

Independent nurse prescribing was introduced in Poland in 2016, with two educational pathways offering different levels of competence. Nurses with a MSN or nurse specialist (NS) may undertake a three-month specialist course enabling them to prescribe drugs and medical devices independently as well as issue referrals for laboratory tests, within a strictly defined scope. Nurses holding a BSN or NS may complete a similar course entitling them to prescribe medications and devices previously ordered by a physician (supplementary prescribing) and to issue laboratory referrals. BSN students, who started their studies from the academic year 2016/2017 and MSN students from 2017/2018, do not have to complete a specialist course in prescribing, as this content is included in the educational content [15].
Under current regulations, nurses may prescribe all drugs as a supplementary prescription, excluding controlled substances (opioids, benzodiazepines, hypnotics) and certain high-potency drugs (e.g., epinephrine, hyoscine butylbromide, digoxin, LABA). This scope does not fully address the needs of palliative care patients, particularly in the context of person-centered, coordinated care, aiming at reducing waiting times and providing comprehensive services at the point of care.
The study included 144 nurses who met the inclusion criteria. According to national data, approximately 7,432 palliative care nurses are employed in Poland, of whom 1,781 are active PNS, representing 24% of the total group. The study sample therefore accounts for approximately 1.9% of the national population. While this poses a limitation to the representativeness of the results, the data obtained offer valuable insights into nurses’ readiness to expand their competencies in the area of medication prescribing.
Our findings confirm that educational level is strongly associated with the use of INP authority. Nurses with an MSN and/or PNS are more likely to prescribe in daily practice. Workplace setting also plays a role: those working in home care have greater opportunities to exercise professional autonomy, as physicians are often absent during visits. In such cases, nurses assess patients’ clinical needs and respond within their scope of practice [14, 16]. Given that community hospice nurses visit patients at least four times more often than physicians, they are well positioned to address ongoing needs. Literature supports that this model is safe, effective, and improves care quality by reducing delays [17].
The study also revealed that the current INP model in Poland is inadequate for meeting the clinical needs of palliative care patients. A key barrier identified was fear of insufficient preparation. Experiences from countries, such as the UK and Ireland, where legislation, professional guidance, and targeted education emphasize advanced practice nursing, suggest that similar measures could strengthen the clinical role of nurses in Poland [18].

International context

In many countries, including the UK, Ireland, the Netherlands, Canada, the US, and Australia, nurses in palliative care have the authority to prescribe controlled drugs, such as strong opioids and benzodiazepines, within their area of practice [12]. This authority is particularly relevant in the management of cancer, chronic pain, and end-of-life care. In the UK, since April 2012, independent prescribers have been authorized to prescribe almost all controlled drugs, with few exceptions [19, 20], while the Netherlands grants nurse specialists unrestricted prescribing rights within their specialty [21]. In Ireland, as of 2017, INPs in palliative care may prescribe the most commonly used opioids, with specified routes of administration [22].
Our survey indicates that Polish nurses, especially those with higher education and working in community palliative care, perceive the need to add co‑analgesics, spasmolytics, steroids, benzodiazepines, antipsychotics, and diuretics to the list of drugs available for independent prescribing.

Implications for practice

The findings indicate that palliative care nurses are willing to expand their scope of practice to include the prescription of selected medicines, such as certain controlled substances. International research shows that expanding nurses’ clinical competence can reduce hospitalizations, re-admissions, and healthcare costs [10]. However, insufficient training remains a major barrier, as conformed by findings from other countries [23]. To ensure that such an expansion is both safe and effective, targeted educational programs in pharmacology, clinical decision-making, and legal aspects of prescribing, should be strengthened at both undergraduate and postgraduate levels [24]. Enhancing nurses’ competence in this area could improve timely access to essential medications, optimize symptom management, and support the delivery of person‑centered palliative care.

Limitations

This study has several limitations. First, the cross‑sectional design captures attitudes and practices at a single-point in time, limiting causal inference. Second, the participation was voluntary, which may have introduced self-selection bias, with more motivated or prescribing-active nurses choosing to respond. Third, the reliance on self-reported data may be subject to recall or social desirability bias. Finally, the sample, although nationwide, may not fully represent all palliative care nurses in Poland.

Conclusions

Strengthening the clinical expertise of nurses in palliative care has the potential to improve access to services, enhance professional confidence, and foster positive attitudes toward advanced competencies in this field. Expanding nurses’ authority, particularly to include prescribing controlled substances, could address unmet patient needs, streamline care delivery, and reduce delays in symptom management. Such developments may also benefit the healthcare system by decreasing hospital admissions, re-admissions, and length of stay, thereby contributing to cost reduction. The findings of this study highlight the importance of aligning legislative frameworks, educational programs, and clinical practice guidelines, to support safe and effective implementation of expanded prescribing rights in palliative care nursing.

Acknowledgements

The authors would like to express their sincere gratitude to Izabela Kaptacz, PhD, MSN, PNS, RN, National Consultant in Palliative Care Nursing (2011–2024), for her invaluable help and support in carrying out the study. Special thanks are extended to all the palliative care nurses, who participated in the national study and made it possible to publish these results.

Disclosures

This research received no external funding.
Approval of the Bioethics Committee was not required.
The authors declare no conflicts of interest.
Appendix is available on the journal’s website.

References