“Whose voice should we listen to?”: Confucian relational ethics and moral distress among Chinese pediatric nurses–a qualitative study

Moral distress is well documented in nursing literature, yet mainstream bioethical frameworks centered primarily on individual autonomy insufficiently explain how family-centered authority, filial piety, and hierarchical norms shape ethical experiences in relational contexts. In China, Confucian relational ethics grant parents strong moral legitimacy in clinical decision-making, creating culturally specific tensions when parental choices conflict with the child’s best interests or with nurses’ professional judgment. This study aimed to explore the pathway of moral distress among Chinese pediatric nurses in tertiary hospitals, moving beyond descriptive accounts to delineate how moral distress is relationally generated, emotionally amplified, and systemically mitigated within a Confucian relational ethics context. A descriptive qualitative design was employed. Semi-structured, in-depth interviews were conducted with 12 pediatric nurses recruited through maximum variation purposive sampling across three tertiary hospitals in China. Data were analyzed using thematic analysis. The findings depict moral distress along a dynamic analytical continuum that reflects its temporal and causal logic. The experience was situationally generated through fractured loyalties within the nurse-child-family triad, where nurses navigated competing obligations between child advocacy, parental authority, and institutional compliance. Pediatric-specific dynamics further amplified these tensions into psychological erosion, as the emotional weight of proxy advocacy and family navigation produced cumulative exhaustion and lingering moral residue. While systemic hierarchies and restricted avenues for ethical expression continually constrained nurses’ capacity to act, participants identified a critical transition from individual endurance to systemic empowerment by highlighting nurse-centered debriefings and dedicated ethical infrastructure as key mechanisms to break the cycle of distress. Rather than a static psychological state, moral distress among Chinese pediatric nurses represents a dynamic experiential pathway driven by culturally grounded relational conflicts and structural constraints. By establishing a coherent narrative from etiology to structural remedies, this study underscores the necessity of implementing multi-level, culturally congruent institutional supports to protect nurses’ moral well-being and sustain high-quality pediatric care.