Ethics in the crossfire: politicised patient care, cultural authority, and nurses’ constrained moral agency

Abstract

Abstract Background Socio-political polarisation increasingly shapes health decisions and clinical encounters, yet little is known about how nurses in low- and middle-income countries navigate conflicts among formal patient rights, family authority, cultural obligations, and politicised beliefs. Nepal provides a particularly important setting because rights-oriented legal reforms coexist with collectivist traditions, institutional resource constraints, and persistent social hierarchies. This study explored how registered nurses in Nepal interpret and manage ethically complex encounters in which patient care is influenced by political, legal, cultural, religious, or familial pressures. Methods A qualitative study was conducted using in-depth, semi-structured interviews with 14 female registered nurses. Data were analysed using reflexive thematic analysis within an interpretivist and constructionist orientation; reporting was informed by the Reflexive Thematic Analysis Reporting Guidelines. The analysis combined semantic and latent engagement with the data, using moral distress and constrained moral agency as the principal ethical lenses. Results Five interconnected themes were constructed: navigating legislative shifts in clinical practice; balancing personal values with nursing obligations; cultural priorities versus evidence-based care; systemic resource gaps and educational shortfalls—a widening chasm between policy and practice; and confronting hierarchies in nurse–patient interactions. Moral distress arose when nurses could discern a patient-centred or professionally responsible course of action but lacked clear policy guidance, institutional support, or sufficient authority to act. Family seniority, religious influence, political connections, and gendered assumptions could displace nurses’ clinical judgement. However, clear protocols, supportive senior clinicians, professional experience, and culturally negotiated care strengthened nurses’ moral agency and enabled ethical action. Conclusions Politicised patient care in Nepal is not limited to overt partisan conflict; it is shaped by the interplay of law, culture, family power, gender, and organisational capacity. Legislative reform alone is insufficient unless healthcare institutions translate patient rights into workable procedures and protect nurses who advocate for ethically appropriate care. Context-specific ethics education, brief unit-based case discussions, clear escalation pathways, and gender-aware organisational support are practical measures that could reduce moral distress and strengthen ethical nursing practice in Nepal and comparable resource-constrained settings. Clinical trial number Not applicable.