Policy Frameworks for Nursing Practice in Community-Based Palliative Care: A Four-Country Comparative Documentary Analysis.

Abstract

Nurses are central to palliative care, yet their community contributions remain undervalued. This study aimed to clarify how political and professional documents conceptualize nursing autonomy in community palliative care. Using the READ (Reading materials, Extracting data, Analyzing data, Distilling findings) methodology, a comparative documentary analysis was conducted in the Netherlands, Portugal, Spain, and the United Kingdom. Sixty-eight strategic documents, identified through systematic searches and expert consultation, underwent targeted qualitative content analysis, combining deductive coding with inductive theme generation. Results reveal a multilevel framework of professional representation: (1) micro-level interventions; (2) meso-level contextual determinants; and (3) macro-level systemic dimensions. A critical tension exists between technical visibility and formal authority. In Portugal and Spain, robust taxonomic infrastructures provide high clinical visibility, yet legal frameworks prioritize "system breadth" over specialized nursing roles. The UK and the Netherlands emphasize "vertical career trajectories," where specialty recognition and advanced education act as levers for clinical agency and nurse-led care. While all country policies prioritize home-based care, differences in how they improve autonomy may influence workforce sustainability and professional migration. These findings suggest that failing to formalize-specialized roles creates "gray zones" of responsibility. Strengthening the structural conditions that support nursing autonomy, including clear role recognition and aligned policy mechanisms, is essential for ensuring timely access to care and the long-term viability of community-based models. This study provides a roadmap for policymakers to reconcile professional agency with the universal right to high-quality care at the end-of-life.