How moral disengagement becomes legitimated and routinised amid competing ethical responsibilities in intensive care nursing: a two-site focused ethnography

Competing responsibilities can leave ethically significant needs unattended in intensive care. To examine how moral disengagement becomes possible, interactionally legitimated and routinised in everyday ICU nursing, and how established practices are challenged or revised. A two-site focused ethnography was conducted from March 2025 to February 2026 in a medical ICU and a surgical ICU in two tertiary public hospitals in China. Participant observation, informal conversations, semi-structured dialogic interviews and longitudinal case tracking generated data. Forty-nine nurses were observed during 50 visits (148 h). Thirty-four nurses completed 54 interviews; 15 were interviewed two or three times. Reflexive thematic analysis used moral disengagement theory as a sensitising framework and attended to interaction and change over time. Four interrelated themes explained situational narrowing of responsibility, provisional legitimation through team interaction, sedimentation of justification into routine, and reopening of ethical evaluation. These processes could overlap, reverse or remain incomplete. Moral disengagement was inferred when an acknowledged ethical cost, divergence from endorsed values and reasoning that reduced self-sanction were linked; urgent prioritisation or non-resumption alone did not establish it. Safety and accountability accounts could close discussion while concern persisted. Patient, peer and managerial encounters reopened evaluation; research interviews also prompted reflection. Recognition and practice change remained uneven and reversible. The findings offer a situated account of moral disengagement that connects moral self-regulation with team interaction and repetition. They suggest that revisiting unresolved comfort and communication needs and protecting opportunities to question established practice may help sustain ethical attention. The effectiveness of these responses requires prospective evaluation.