Layered moral distress in end-of-life nursing under occupation: A hermeneutic inquiry

BackgroundNurses providing end-of-life care in conflict-affected settings navigate cultural traditions, professional duties, and structural violence. Existing frameworks address cultural and institutional dimensions separately but do not account for their simultaneous interaction under protracted conflict.AimThis study explored how nurses' beliefs, intersecting with structural conditions, shape end-of-life care in a conflict-affected setting.Research designA Gadamerian hermeneutic inquiry employed semi-structured interviews with dialogical openness. Data were analyzed using hermeneutic principles through iterative movement between transcripts and data.Participants and research contextThirteen nurses were recruited from three hospitals in the occupied West Bank via purposive and snowball sampling. Interviews were conducted in Arabic.Ethical considerationsEthical approval was obtained from the Palestinian Ministry of Health Ethics Committee and the university IRB. All participants provided written informed consent.FindingsFour themes emerged: sacred framing of death and suffering; family as moral authority; layered moral distress under structural constraint; and resilient adaptation under structural constraint.DiscussionLayered moral distress is proposed as an analytical concept for nursing ethics in conflict settings, distinguished from cumulative moral distress, moral residue, and moral injury by its simultaneous, multiplicative interaction of cultural, professional, and structural layers without institutional resolution. Findings suggest a contextual refinement to Leininger's Theory: under structural-political violence, the political dimension can reorganize culturally congruent care.ConclusionsInformal adaptive practices warrant formal recognition. Layered moral distress offers a transferable framework for other conflict-affected settings. Future research should extend this inquiry to comparable contexts with attention to contextual specificity.