Navigating institutional cracks: Ethical dilemmas and resilience in narrative nursing practice

BackgroundNarrative nursing is recognized as a vital relational ethical practice for upholding patient dignity and counteracting the dehumanizing effects of the biomedical model. However, its implementation in China's high-pressure, task-oriented hospital environments creates profound ethical tensions. The clash between the ideal of humanistic care and the reality of efficiency logic often precipitates moral distress among nurses, yet their lived ethical experiences within these systemic constraints remain under-explored.AimTo explore the ethical challenges, moral distress, and resilience strategies encountered by Chinese clinical nurses when implementing narrative nursing in resource-constrained settings.Research designA qualitative descriptive phenomenological design was adopted to capture the essence of nurses' lived experiences.Participants26 registered nurses were recruited via purposive sampling from six clinical departments (including Oncology, Obstetrics, and Hepatobiliary Surgery) within a tertiary Grade-A hospital in China. Data were collected through six focus group discussions.Ethical considerationsThe study was approved by the Institutional Review Board of The Eighth Affiliated Hospital of Southern Medical University. Written informed consent was obtained from all participants, and anonymity was strictly maintained throughout the data analysis process.FindingsThe analysis revealed three core themes: (1) Spatial Constraints and Privacy Dilemmas: The lack of auditory privacy in crowded wards created a "panopticon" environment, transforming sensitive narratives into public performances and compelling patients to engage in self-censorship, thereby compromising dignity; (2) Systemic Barriers and Moral Distress: The conflict between "fast time" (task completion) and "slow time" (narrative engagement) rendered narrative care as invisible work that is unrecognized by performance appraisals. Nurses faced the risk of becoming containers of trauma due to a lack of institutional emotional support; (3) Strategies to Maintain Moral Agency: Nurses reclaimed agency by utilizing fragmented time to construct ethical moments. They derived reciprocal professional nourishment and cognitive reframing from patient interactions, which served as a sustainable source of moral resilience.ConclusionImplementing narrative nursing in this context is a profound struggle against spatial injustice and structural devaluation. Relying solely on nurses' individual volunteerism to sustain this practice is inherently unsustainable. To foster a genuine ethical climate, healthcare institutions must move beyond rhetoric to legitimate narrative engagement as a core competency, re-engineer clinical spaces for privacy, and establish systemic safety valves for emotional labor.