The ethical weight of monitoring-as-witnessing: ICU nurses’ vicarious trauma

Background Intensive care nurses repeatedly witness suffering, dying, grief, and conflict. In contemporary intensive care, protocols and monitoring routines can compress nursing work into execution and vigilance, limiting opportunities to exercise moral agency and creating ethically fraught “witnessing” positions. Research objectives To explore how intensive care nurses experience vicarious trauma, and how moral agency, ethical tensions, and organizational conditions shape its accumulation and repair. Research design A qualitative study using face-to-face semi-structured interviews and reflexive thematic analysis. Participants and research context Fifteen registered nurses from a general intensive care unit in eastern China, purposively sampled for maximum variation in gender, professional title, experience, and recent high-impact exposures. Ethical considerations Ethical approval was obtained from the Ethics Committee of The First Affiliated Hospital of Zhejiang Chinese Medical University (approval number: 2025-KLS-184-02). Written informed consent was obtained; confidentiality and a distress protocol were applied. Findings Four themes were generated: (1) occupational boundary permeation and resonance, including identity mirroring, emotional absorption, and moral tension; (2) a spectrum of adaptation, where defensive distancing functioned as a strategy of moral survival under repeated exposure; (3) fractures in professional meaning and points of rupture, including constrained voice and experiences of powerless witnessing; and (4) meaning reconstruction in the cracks, reflecting moral repair through process-oriented care, renewed boundaries, and re-grounding in dignity-preserving practice. Conclusions Vicarious trauma in intensive care nursing is not only an individual psychological burden but an ethical and organizational phenomenon shaped by constrained moral agency and ethically contested trajectories of care. Interventions should move beyond individualized resilience and strengthen ethical infrastructures that legitimize nursing voice, support reflective processing, and enable ethically defensible practice in high-acuity settings.