Moral Distress Among Hospice Nurses in China: A Mixed‐Methods Study Informed by an Ecological Systems Perspective

AIM: To examine moral distress and associated factors among nurses involved in hospice care in China and explore how these experiences are shaped across individual, relational, organisational and sociocultural contexts. BACKGROUND: Hospice nurses frequently encounter ethically challenging situations. In China, moral distress may be further shaped by organisational constraints, family-centred decision-making and sociocultural expectations surrounding end-of-life care. METHODS: A convergent parallel mixed-methods design was used and reported in accordance with the Good Reporting of a Mixed-Methods Study (GRAMMS) guidelines. Quantitative data were collected from 295 nurses using measures of moral distress, moral resilience, work-family conflict and hospital ethical climate. Semi-structured interviews were conducted with 15 nurses purposively selected from the quantitative sample. The datasets were analysed separately and integrated during interpretation. FINDINGS: Moral distress was associated with factors across individual, relational and organisational contexts. Greater moral resilience and a more supportive ethical climate were associated with lower moral distress, whereas greater work-family conflict was associated with higher moral distress. Qualitative findings complemented these associations by highlighting how nurses described ethically challenging care in relation to sociocultural expectations surrounding life preservation and family-led decision-making. DISCUSSION: The integrated findings suggest that moral distress is best understood within overlapping individual, relational, organisational and sociocultural contexts rather than through any single factor in isolation. CONCLUSION: Supporting hospice nurses experiencing moral distress may require multilevel support addressing resilience-related resources, work-family needs, organisational ethical support and culturally responsive care. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Support should extend beyond individual resilience-building to include family-supportive work arrangements, accessible organisational ethics resources and culturally responsive approaches to end-of-life communication and decision-making.