Path analysis the influence of self-efficacy and professional identity on attitudes toward prescriptive authority among oncology nurse specialists

Abstract

BACKGROUND

Global tumor incidence rises and therapies advance, driving oncology nursing specialization. Granting nurses prescriptive authority optimizes care but polarizes nurses' attitudes due to factors like risk and competence, hindering policy implementation.

AIM

To investigate the current status of the attitudes of oncology specialist nurses toward having prescribing authority, specifically concerning symptom management and supportive care in oncology practice, and we conducted a path analysis of their influencing factors.

METHODS

As participants in the survey, oncology specialist nurses working in hospitals of different grades in Jiangsu Province were selected from March 2025 to May 2025 using a stratified sampling method. The questionnaires were administered using the general information questionnaire, the beliefs and attitudes about nurses' prescriptive authority scale, the nurses' professional identity scale, and the self-efficacy scale. Pearson’s method was used to analyze the correlation between beliefs and attitudes about the prescriptive authority, professional identity, and self-efficacy of nurses. Multiple linear regression was performed to analyze the factors influencing the beliefs and attitudes of nurses’ prescriptive authority. The Amos plug-in was used to construct structural equation models to analyze the influencing pathways.

RESULTS

A total of 329 questionnaires were distributed, and 328 valid questionnaires were returned (effective recovery rate: 99.70%). The total score of the 328 oncology nurses on the beliefs and attitudes about nurses' prescriptive authority scale was 101.88 ± 15.13, indicating a moderately high level. Univariate analysis revealed that gender and hospital grade were associated with this score (P < 0.05). The Pearson correlation analysis revealed that self-efficacy was positively correlated with the scores of the beliefs and attitudes about nurses’ prescriptive authority scale and the nurses’ professional identity scale (r = 0.4999, P < 0.0001 and r = 0.7048, P < 0.05, respectively), whereas occupational identity was positively correlated only with the former (r = 0.6209, P < 0.05). Multiple linear regression analysis revealed occupational identity and self-efficacy as the factors influencing the scores of the beliefs and attitudes about nurses’ prescriptive authority scale (P < 0.05). The results of the path analysis revealed that self-efficacy significantly positively affected nurses’ occupational identity and their beliefs and attitudes about having prescriptive authority; occupational identity played a mediating role between the two, with a mediating effect accounting for 54.46% of the total effect, and the structural equation model was well-fitted.

CONCLUSION

Oncology nurses have more positive attitudes toward prescriptive authority. In addition, self-efficacy positively and indirectly affects nurses’ attitudes toward prescriptive authority through the mediating effect of occupational identity. This can be used as a basis for clinical practice to take targeted measures to improve nurses’ self-efficacy and occupational identity, thus creating favorable conditions for effectively implementing the policy of prescriptive authority.

Key Words: Oncology nurse specialists; Self-efficacy; Professional identity; Nurse prescribing authority; Attitudes

Core Tip: This study examined the attitudes of oncology specialist nurses in Jiangsu Province toward prescribing authority and analyzed the influencing factors through a structured survey and path analysis. The model demonstrated good fit, indicating a robust relationship among these variables. The study concludes that oncology nurses hold positive attitudes toward prescribing authority, with self-efficacy playing a crucial role in shaping these attitudes both directly and indirectly through occupational identity. These findings provide a basis for clinical interventions aimed at enhancing nurses' self-efficacy and professional identity, thereby supporting the effective implementation of prescribing authority policies.

INTRODUCTION

With the continuous rise of global tumor incidence and the popularization of refined diagnostic and therapeutic technologies like targeted therapy and immunotherapy, oncology nursing has evolved from primary care to a specialized and higher-order practice[1,2]. Giving nurses prescriptive authority has become an important step in this process of reforming oncology nursing practices. Nurses’ prescriptive rights are the rights granted to nursing staff to prescribe drugs and related examinations in clinical practice; aimed as a supplement to physician prescriptive rights, these can not only optimize the symptom management process of oncology patients and improve the continuity and timeliness of healthcare services but also help partially alleviate the imbalance between the supply and demand of healthcare resources[3]. In the context of oncology nursing, nurses’ prescribing authority typically focuses on managing treatment-related symptoms and supportive care needs, such as prescribing medications for pain, nausea, vomiting, and constipation and coordinating related diagnostic tests to optimize patient comfort and quality of life. This scope typically distinguishes it from prescribing core anti-tumor therapies like chemotherapy or immunotherapy, which remain primarily under physician authority in current practice models. However, since the launch of pilot nurses’ prescriptive authority in China in 2017[4], there has been significant polarization of nurses’ attitudes toward prescriptive authority: Some nurses have a positive and supportive attitude toward prescriptive authority as a reflection of the enhancement of their professional value, whereas others are concerned about or even resistant due to factors such as responsibility risk and competence anxiety[5]. This attitudinal polarization is a key limitation restricting the smooth implementation of policies related to nurses’ prescriptive rights. A detailed analysis of the psychological mechanism behind this phenomenon is essential for promoting the implementation of the policy.

Self-efficacy refers to an individual’s confidence in their ability to perform a specific task or achieve a goal[6], whereas professional identity refers to the degree to which an individual recognizes their professional role[7]. Both self-efficacy and professional identity are closely related to nurses’ attitudes toward prescribing authority, which may affect their acceptance of and willingness to perform prescribing authority[8,9]. However, to our knowledge, no study has analyzed the relationships among the three. In this study, we investigated the situation of oncology nurses’ attitudes toward prescribing authority, analyzed the effects of self-efficacy and professional identity on their attitudes toward prescribing authority, and provided empirical evidence for the development of targeted intervention strategies to promote the transformation of their prescribing authority from a policy pilot to clinical effectiveness.

MATERIALS AND METHODS

General information

Oncology nurses working at various hospitals in Jiangsu Province were recruited to conduct the survey. The inclusion criteria were as follows: (1) Oncology nurses working in oncology-related departments; (2) Holding a license to practice as a nurse; (3) Aged > 18 years; and (4) Voluntarily participating in this study with a signed informed consent form. The exclusion criteria were as follows: Nurses requiring further training, interns, and nurses on maternity or sick leave. This study was approved by the Medical Ethics Committee of Haian Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Ethics No. HZYLL2022-084.

Survey instruments

General information questionnaire: General information about the study participants was collected, including age, gender, nursing experience (years), professional title, education, hospital grade, nurse’s ability level, specialized nurse grade, participation in the nursing department outpatient visits, role as master’s supervisor, and years since obtaining the specialized nurse certificate.

Nurses' beliefs and attitudes about nurses’ prescriptive authority scale: The scale[10] was used to measure the attitudes of nurses toward prescriptive authority. The scale comprises four dimensions, including the perceived need for prescriptive authority, self-efficacy in exercising prescriptive authority, perceived benefits of prescriptive authority, and perceived barriers to exercising prescriptive authority. It comprises 27 items evaluated on a five-point Likert scale. Except for items 19, 20, 25, and 27, which were reverse-scored, each item was rated from 1 (strongly disagree) to 5 (strongly agree). The total score ranged from 27 to 135, with higher scores indicating stronger beliefs and intentions about the implementation of nurses’ prescriptive authority. The Cronbach's alpha coefficient of the scale in this survey was 0.958, and the Cronbach's alpha coefficients of all dimensions were > 0.880. It can be used to evaluate the beliefs and attitudes of nurses toward nurses’ prescriptive authority effectively. The scale was easily understood by the participants; the number of entries was acceptable, and the assessment time was short.

Nurses' professional identity scale: The scale[11] was used to assess their level of professional identity. Although the original scale used a five-point Likert format, we adapted it to a seven-point scale (1 = “completely disagree” to 7 = “completely agree”) to enhance response sensitivity. The scale comprised 21 items, with the total score ranging from 21 to 147, with higher scores indicating a higher level of professional identity. The Cronbach’s alpha coefficient of the scale in this survey was 0.979, upholding its utility to evaluate the professional identity of nurses in China. The adaptation was validated through pilot testing (n = 30 oncology nurses), which showed strong item-total correlations (r = 0.72-0.89) and maintained structural validity (CFI = 0.94 in confirmatory factor analysis).

The self-efficacy scale: The general self-efficacy scale[12] was used to assess nurses’ self-efficacy. The scale comprises 10 items and is rated on a four-point Likert scale, with each item rated from 1 (not at all true) to 4 (completely true). The total score ranged from 10 to 40, with higher scores indicating greater self-efficacy of nurses. The Cronbach’s alpha coefficient of the scale was 0.968, indicating high reliability of the instrument for use in this study. The content of the scale is linguistically simple and semantically clear and is suitable for assessing the confidence and coping ability of a group of nurses in complex clinical tasks.

Data collection and quality control

This study adopted the questionnaire survey method. The questionnaire was administered using Wenjuanxing. The researchers sent the QR code of the questionnaire to the respondents via WeChat. The purpose, significance, and filling rules of this survey were clearly stated at the beginning of the questionnaire. The respondents were also informed that filling out this questionnaire represented consent to participate in this research. This survey was filled out anonymously, and the questionnaire could be submitted only after all the questions were answered. A total of 329 questionnaires were collected, excluding one unqualified questionnaire, such as the answer homogeneity law, and 328 valid questionnaires were recovered, indicating a validity rate of 99.70%.

Statistical analysis

All data were analyzed using the SPSS 26.0 software. The Kolmogorov-Smirnov test was conducted to test whether the measurement data followed a normal distribution. The data that conformed to a normal distribution were expressed as the mean ± SD, and to determine the differences between groups, an independent/paired-samples t-test was performed. The data that did not follow a normal distribution were expressed as the median (interquartile range) [M (P25, P75)], and the Mann-Whitney rank-sum test was used to determine between-group differences. Count data were expressed as the number of cases and rate [n (%)], and the χ² test was used to determine between-group differences. Pearson correlation analysis was performed to examine the correlation of the scale scores. Multiple linear regression analysis was performed to determine the factors influencing nurses’ beliefs and attitudes about their prescriptive authority. The Amos plug-in was used for path analysis. The SPSS extension module process was used for the mediation effect test. All differences were considered statistically significant at P < 0.05.

RESULTS

General information on oncology nurses

A total of 328 oncology nurses (age range, 19-53 years; mean age, 33.83 ± 6.00 years) were included. The general information of the 328 oncology nurses is shown in Table 1.

Table 1 General information.

Sports event	Clusters	n	Composition ratio (%)
Age (years)	< 30	73	22.26
	30-39	208	63.41
	40-49	41	12.50
	≥ 50	6	1.83
Distinguishing between the genders	Male	53	16.16
	Female	275	83.84
Nursing experience (years)	< 3	32	9.76
	3-5	25	7.62
	6-10	77	23.48
	11-20	161	49.09
	> 20	30	9.15
Level of hospital	Primary hospital	29	8.84
	Secondary hospital	32	9.76
	Tertiary hospital	267	81.40
Title	Registered nurse	43	13.11
	Senior nurse	64	19.51
	Nurse manager	164	50.00
	Associate chief nurse	46	14.02
	Chief nurse	11	3.35
Highest education level	Secondary/tertiary	32	9.76
	Undergraduate	272	82.93
	Postgraduate student	24	7.32
Duties	Charge nurse	167	50.91
	Care team leader	106	32.32
	Head nurse	40	12.20
	Director/deputy director of nursing	10	3.05
	Nursing department officer	5	1.52
Nurse competence	N1	53	16.16
	N2	102	31.10
	N3	136	41.46
	N4	37	11.28
Specialist nurse grade	Courtyard	91	27.74
	Municipal	79	24.09
	Provincial level (e.g., government)	119	36.28
	National level (e.g., nature reserve)	39	11.89
Participation in outpatient nursing clinic visits	No	207	63.11
	Yes	121	36.89
Master's degree	No	304	92.68
	Yes	24	7.32
Years of practice as a specialist oncology nurse	1-5	254	77.44
	6-10	52	15.85
	> 10	22	6.71

Oncology nurses' beliefs and attitude scores, self-efficacy scores, and professional identity scores regarding prescriptive authority

The 328 oncology nurses had an average total score of 101.88 ± 15.13 for beliefs and attitudes about having prescriptive authority, 122.79 ± 20.10 for professional identity, and 32.06 ± 6.38 for self-efficacy (Table 2).

Table 2 Oncology nurses' beliefs and attitudes scores, professional identity scores, and self-efficacy scores regarding prescribing authority (mean ± SD).

Dimension or total score	Entry	Score	Average score for each entry
Sensing the need for prescriptive authority	6	23.61 ± 4.61	3.94 ± 0.77
Self-efficacy for exercising prescriptive authority	6	23.21 ± 4.83	3.87 ± 0.81
Perceived benefits of prescriptive authority	10	42.06 ± 7.53	4.21 ± 0.75
Perceived barriers to exercising prescriptive authority	5	12.99 ± 4.69	2.60 ± 0.94
Beliefs and attitudes toward prescriptive authority	27	101.88 ± 15.13	3.77 ± 0.56
Professional identity	21	122.79 ± 20.10	5.85 ± 0.96
Self-efficacy	10	32.06 ± 6.38	3.21 ± 0.64

Correlation analysis of oncology nurses' beliefs and attitudes scores, professional identity scores, and self-efficacy scores regarding prescriptive authority

Pearson's correlation analysis revealed that self-efficacy was positively correlated with nurses’ beliefs and attitudes about having prescriptive authority and professional identity (r = 0.4999, P < 0.0001 and r = 0.7048, P < 0.0001, respectively). Professional identity was positively correlated with nurses’ beliefs and attitudes about having prescriptive authority (r = 0.6209, P < 0.0001; Table 3).

Table 3 Correlation analysis of oncology nurses' beliefs and attitudes scores, self-efficacy scores, and professional identity scores regarding prescriptive authority [r value (P value)].

Norm	Nurse prescriptive authority beliefs and attitudes	Professional identity	Self-efficacy
Nurses’ beliefs and attitudes about having prescriptive authority	1	-	-
Professional identity	0.6209 (0.0000)	1
Self-efficacy	0.4999 (0.0000)	0.7048 (0.0000)	1

Univariate analysis of oncology nurses' beliefs and attitudes toward nurses' prescribing authority

The results of the univariate analysis revealed that the gender of the nurses and the level of the hospital where they were employed significantly affected the scores of their beliefs and attitudes about having prescriptive authority (P < 0.05, Table 4).

Table 4 Univariate analysis of oncology nurses’ beliefs and attitudes toward their prescriptive authority (mean ± SD).

Sports event		n	Score	t value/F	P value
Age (years)	< 30	73	101.03 ± 15.93	0.2532	0.8590
	30-39	208	101.83 ± 15.31
	40-49	41	103.17 ± 12.85
	≥ 50	6	104.83 ± 11.72
Gender	Male	53	106.34 ± 15.02	2.369	0.0184
	Female	275	101.01 ± 14.99
Nursing experience (years)	< 3	32	101.46 ± 15.50	0.2615	0.9025
	3-5	25	102.52 ± 14.03
	6-10	77	101.06 ± 16.82
	11-20	161	102.58 ± 14.52
	> 20	30	100.13 ± 13.82
Level of hospital	Primary hospital	29	104.86 ± 13.77	3.442	0.0332
	Secondary hospital	32	95.66 ± 16.21
	Tertiary hospital	267	102.30 ± 14.94
Title	Registered nurse	43	102.93 ± 15.24	1.425	0.2252
	Senior nurse	64	103.70 ± 15.76
	Nurse manager	164	99.95 ± 15.13
	Associate chief nurse	46	104.41 ± 14.10
	Chief nurse	11	105.18 ± 10.50
Highest education level	Secondary/tertiary	32	102.25 ± 15.57	1.422	0.2428
	Undergraduate	272	101.40 ± 15.33
	Postgraduate student	24	106.79 ± 10.64
Duties	Charge nurse	167	101.22 ± 15.28	0.5714	0.6836
	Care team leader	106	101.87 ± 15.38
	Head nurse	40	102.80 ± 14.80
	Director/deputy director of nursing	10	108.10 ± 7.80
	Nursing department officer	5	104.20 ± 14.66
Nurse competence	N1	53	101.92 ± 16.82	2.599	0.0522
	N2	102	98.97 ± 15.64
	N3	136	102.79 ± 13.93
	N4	37	106.43 ± 13.73
Specialist nurse grade	Courtyard	91	100.74 ± 16.22	2.536	0.0567
	Municipal	79	99.48 ± 18.47
	Provincial level (e.g., government)	119	102.62 ± 11.74
	National level (e.g., nature reserve)	39	107.10 ± 12.45
Participation in outpatient nursing clinic visits	No	207	101.57 ± 14.81	0.4740	0.6358
	Yes	121	102.39 ± 15.63
Master's degree	No	304	101.57 ± 15.40	1.293	0.1969
	Yes	24	105.71 ± 10.36
Years of practice as a specialist oncology nurse	1-5	254	101.04 ± 15.30	2.783	0.0633
	6-10	52	106.38 ± 13.09
	> 10	22	100.91 ± 15.74

Multiple linear regression analysis of oncology nurses' beliefs and attitudes toward having prescriptive authority

Multiple linear regression analysis was performed on the basis of the above univariate correlation analysis using the total score of the beliefs and attitudes about nurses’ prescriptive authority scale as the dependent variable. The goodness of fit of the model for this regression analysis showed the following: Correlation coefficient r = 0.5954 and coefficient of determination R² = 0.3545. In addition, ANOVA showed F = 35.36 (P < 0.0001), collectively implying that this regression model was statistically significant. The results revealed that both professional identity and self-efficacy were influential factors in the belief and attitudes scores of nurses’ prescriptive authority (P < 0.0001), together explaining 35.45% of the variance (Table 5).

Table 5 Multiple linear regression analyses of beliefs and attitudes about oncology nurses’ prescriptive authority.

Factor	Unstandardized coefficient		Standardized coefficient	t value	P value	Covariance statistics
	β	SE	β			tolerances	VIF
Gender (female)	-1.7447	1.9068	-0.0425	-0.9150	0.3609	0.9312	1.0739
Level of the hospital in which it is located (level II)	-4.9737	3.1676	-0.0976	-1.5702	0.1174	0.5192	1.9260
Level of the hospital in which it is located (tertiary)	1.1699	2.4393	0.0301	0.4796	0.6318	0.5092	1.9639
Professional identity	0.3126	0.0450	0.4154	6.9482	0.0000	0.5608	1.7830
Self-efficacy	0.4906	0.1437	0.2071	3.4142	0.0007	0.5450	1.8347

Path analysis

Based on the results of the Pearson correlation analysis, nurses’ prescriptive authority beliefs and attitudes scores, self-efficacy scores, and professional identity scores were included in the path analysis. The structural equation model had χ² = 1.0466, P = 0.3063, χ²/df = 1.0466, a CFI value of 0.9976, and an RMSEA of 0.0119, suggesting a good fit (Figure 1 and Table 6). The results of the path analysis revealed that self-efficacy had a significant positive effect on nurses’ beliefs and attitudes about their professional identity and prescriptive authority (standardized path coefficient = 0.6748, P < 0.05; standardized path coefficient = 0.2249, P < 0.05). Occupational identity had a significant positive effect on nurses’ beliefs and attitudes about having prescriptive authority (standardized path coefficient = 0.3995, P < 0.05; Table 7). Professional identity mediated the relationships between self-efficacy and nurses’ beliefs and attitudes about having prescriptive authority, with the mediating effect accounting for 54.46% of the total effect (Table 8).

Figure 1 Path analysis. Solid arrows indicate significant positive paths. Standardized β coefficients are shown next to each arrow. All paths are significant at P < 0.001.

Table 6 Test results of the fit indicators of the structural equation modeling.

Commonly used indicators	χ2	df	P value	χ2/df	GFI	RMSEA	TLI	CFI	NFI	NNFI	IFI
Standard of judgment	-	-	> 0.05	< 3	> 0.9	< 0.10	> 0.9	> 0.9	> 0.9	> 0.9	> 0.9
Value	1.0466	1	0.3063	1.0466	0.9976	0.0119	0.9994	0.9999	0.9968	0.9994	0.9999
Is it up to the standard?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

Table 7 Summary of model regression coefficients.

X - Y	Unstandardized path coefficients	SE	z (CR value)	P value	Standardized path factor
Self-efficacy - professional identity	2.0796	0.1256	16.5611	0.0000	0.6748
Self-efficacy - nurses’ beliefs and attitudes about their prescriptive authority	0.5334	0.1451	3.6764	0.0002	0.2249
Professional identity - nurses’ beliefs and attitudes about their prescriptive authority	0.3075	0.0471	6.5307	0.0000	0.3995

Table 8 Significance test of the mediating effect.

Pathway relationship	Efficiency value	LLCI	ULCI	P value	Percentage (%)
The mediating effect: Self-efficacy - Professional identity - Beliefs and attitudes about their prescriptive authority	0.6390	0.3543	0.9849	-	54.46
Direct effect: Self-efficacy - Beliefs and attitudes about their prescriptive authority	0.5343	0.2544	0.8142	0.0002	45.54
Total effect: Self-efficacy - Beliefs and attitudes about their prescriptive authority	1.1733	0.9490	1.3976	0.0000	100.00

LLCI: Lower limit confidence interval; ULCI: Upper limit confidence interval.

DISCUSSION

Oncology patients have complex conditions with multidimensional needs, such as pain management, symptom control, and palliative care, requiring utmost professionalism and timeliness of nursing care[13]. Expansion of nursing responsibilities by granting them prescriptive authority is receiving increasing attention as an approach to improve the quality of services[14]. Oncology nurses are directly involved in the overall management of patients, and their attitudes toward and acceptance of prescriptive authority directly affect the quality of care and patient prognosis[15]. Therefore, understanding the attitudes of oncology nurses toward prescriptive authority is important for optimizing healthcare, improving patient experience, and promoting the development of the nursing profession.

In this study, we found that oncology nurses’ beliefs and attitudes toward having prescriptive authority were overall moderately high, indicating that nurses of this specialty have a more positive attitude toward prescriptive authority, particularly for symptom management and supportive care. However, the translation of these attitudes into clinical practice is inevitably mediated by macro-level social and systemic factors. Although our path analysis confirms that self-efficacy and professional identity are critical psychological drivers of the development of this attitude, the implementation of giving prescriptive authority to nurses faces heterogeneous real-world constraints across healthcare settings. Critically, implementation of prescriptive authority within the scope defined for this study, which is to grant prescriptive authority primarily for symptom management and supportive care needs (e.g., prescribing analgesics, antiemetics, laxatives, or ordering relevant tests like electrolytes or basic imaging within protocols, typically applicable in outpatient follow-up, symptom clinics, or discharge coordination), suggests that nurses perceive significant value in exercising their prescriptive authority to enhance nursing efficiency, expand their professional competence in core symptom management domains, and ultimately improve patient outcomes. This contrasts with Haririan et al’s report[16] of polarized attitudes among general nurses, suggesting that our specialist cohort’s consensus reflects oncology nursing’s unique symptom management demands. Successful implementations exist where prescribing authority is established; British Oncology Nurse Independent Prescribers significantly improve symptom control through timely medication adjustments[17], and United States Oncology Clinical Nurse Specialists routinely manage supportive care prescriptions[18]. According to the theory of planned behavior, a more positive attitude and a stronger willingness to perform a behavior can develop when the individual is convinced that the behavior will produce significant benefits[19]. Thus, the results of this study suggested that oncology nurses have a good foundation for promoting the practice of prescription rights policy at the cognitive level, which may contribute to the effective implementation of the policy and the promotion of the system.

According to the social cognitive theory, psychological variables are important intrinsic factors that influence individual attitudes and behaviors[20]. For example, Zoromski and Frazier[21] reported that enhancing patients’ self-efficacy can help improve their treatment adherence, and Pan et al[22] reported that improving nurses’ professional identity can promote career planning. These studies suggest that psychological variables play a key role not only in the decision-making process and behavioral regulation but also in the formation of nurses’ attitudes toward prescriptive authority. However, most studies on factors influencing nurses’ attitudes toward prescriptive authority have focused on demographic characteristics, such as age, gender, education, and title[23,24], and they lack an assessment of psychological variables. In this study, psychological variables were introduced to determine their influence on nurses’ attitudes toward prescriptive authority. The results revealed that professional identity and self-efficacy influence nurses’ beliefs and attitudes toward prescriptive authority. To analyze the reasons, self-efficacy, a core concept in social cognitive theory, reflects an individual’s subjective judgment of their ability to accomplish a specific task, and nurses with a high level of self-efficacy are usually more confident in taking up complex clinical tasks with greater independence and initiative[25]. Therefore, they are more likely to recognize and accept prescriptive authority as an extension of their duties. Professional identity, on the other hand, reflects nurses’ perception of the value of their professional roles and their emotional belonging; a higher level of professional identity is associated with greater likelihood of nurses showing positive career development intentions and breaking through the limitations of traditional nursing role[26], thus maintaining a more positive attitude toward prescriptive authority.

The results of multiple linear regression analysis revealed professional identity and self-efficacy as key factors influencing nurses’ beliefs and attitudes about having prescriptive authority (P < 0.05). Although China began piloting prescriptive authority for nurses in 2017[4], Western implementations show instructive parallels: Studies from the United Kingdom/United States reveal similarly positive attitudes among oncology nurses, particularly regarding prescribing for symptom management[27,28]. When comparing with domestic studies, our attitude scores (101.88 ± 15.13) significantly exceed Zhong et al’s reports from general nurses (97.79 ± 13.30)[9] and the attitude rate was basically consistent with that of 95.27% of nurses in Zhao et al's study[29], who were willing to become prescribing nurses. This divergence likely reflects: (1) Oncology specialization: Complex symptom management demands increase receptiveness to prescribing authority; (2) Temporal progression: Policy maturation since 2017 pilots has normalized prescribing concepts; and (3) Regional advantages: Jiangsu's advanced healthcare infrastructure fosters innovation acceptance. However, China has unique challenges, including unclear delineation of responsibilities between physicians and nurses[27], heightened concerns about legal risks[5], and the absence of comprehensive legislative frameworks that clearly define nurses’ prescribing scope. This contrasts with established Anglo-American models wherein standardized competency frameworks and liability protections facilitate implementation[28]. Future reforms should address these systemic barriers while leveraging nurses’ psychological readiness. Notably, male nurses expressed significantly stronger support for prescriptive authority than their female counterparts (106.34 ± 15.02 vs 101.01 ± 14.99, P = 0.018), possibly reflecting heightened motivation for career advancement in a female-dominated profession where role expansion confers professional legitimacy. Similarly, nurses in tertiary hospitals reported more positive attitudes than those in secondary hospitals (102.30 ± 14.94 vs 95.66 ± 16.21, P = 0.033), which is likely attributable to greater exposure to policy pilots, enhanced institutional resources (e.g., decision support systems), and more extensive experience of managing complex cases, collectively contributing to prescribing confidence. In addition, while not statistically significant in our regression model, higher competency nurses (N3-N4) showed a trend toward stronger support for prescriptive authority (N4: 106.43, N3: 102.79) compared to junior nurses (N1: 101.92, N2: 98.97; P = 0.052). This pattern suggests that clinical expertise amplifies the mediating effect of self-efficacy through professional identity as the demonstrated competence of senior nurses likely reinforces their confidence in undertaking prescribing responsibilities. The results of the path analysis revealed that self-efficacy had a significant positive relationship with professional identity and attitudes of nurses toward prescriptive authority. Occupational identity mediated this relationship with a robust effect (54.46% of the total effect). This highlights professional identity as the primary psychological channel through which self-efficacy influences prescribing attitudes. First, nurses with high levels of self-efficacy have greater confidence in their professional competence. This competence confidence reinforces their professional identity as specialized nurses and makes them more inclined to support taking up prescriptive authority as an expansion of their professional role[29]. Second, an increase in professional identity further contributes to nurses’ greater willingness to take up more responsibilities, such as prescriptive authority, and develop more positive attitudes. Thus, professional identity serves as an important psychological mechanism linking competence perceptions and behavioral attitudes, acting as a bridge between the two. The results of this study emphasized the importance of focusing on the shaping of nurses’ intrinsic psychological mechanisms along with knowledge and skills training in promoting the practice of nurses’ prescriptive authority. Through multilevel interventions, such as professional development support, job empowerment, role coaching, and organizational identity reinforcement, the self-efficacy and professional identity of nurses can be enhanced to provide a solid psychological foundation for effective implementation and clinical transformation of the prescriptive authority of nurses.

CONCLUSION

This study revealed that oncology nurses had a more positive attitude toward prescriptive authority. Moreover, path analysis revealed that self-efficacy had a significant positive effect on professional identity and nurses’ attitudes toward prescriptive authority and that professional identity played a mediating role between the two. To promote nurses’ prescriptive authority, targeted measures should be taken to improve their self-efficacy and professional identity to create favorable conditions for the effective implementation of the policies related to prescriptive authority. However, this study has several limitations. First, the sample was drawn solely from Jiangsu Province, which may limit the generalizability of our findings to regions with divergent socioeconomic contexts. Second, although we identified institution-level differences, we did not quantitatively measure critical social determinants, such as regional disparities in medical insurance reimbursement policies for nurse-prescribed drugs, drug availability constraints in primary care settings of economically underdeveloped areas, and variability in primary healthcare resources. Consequently, our model could not assess how these systemic factors moderate the relationship between psychological variables and prescribing authority implementation. Future multicenter studies should incorporate these variables to develop a socio-ecologically grounded implementation framework.