Tensions, adaptation, and meaning-making of emergency nurses' ethical competence in digital health environments: A qualitative study.

AIM: This study aimed to explore how emergency department (ED) nurses demonstrate ethical competence in digitally enhanced acute care settings. Specifically, it examined their practical responses to internal ethical tensions, adaptive strategies, and professional identity reconstruction. By capturing real-time micro-ethical negotiations, the research provides empirically grounded evidence to guide human-centred digital health system design, context-sensitive ethics education, and sustainable psychological support in high-stress environments. METHODS: Guided by a constructivist paradigm, this qualitative study adopted Braun and Clarke's Reflexive Thematic Analysis (RTA). Between March and June 2025, 18 registered ED nurses were recruited through a purposive and maximum variation sampling from three tertiary hospitals in Shenzhen, Guangdong Province, China. Data were collected semi-structured in-depth interviews (40-65 minutes) and supplemented by de-identified digital artefacts (electronic triage logs, handover notes, and reflective journals). Analysis was facilitated by NVivo 14, with rigour ensured through the 32-item COREQ checklist, member checking, peer debriefing, and reflexive journaling. RESULTS: Four interconnected themes emerged: (1) the tension between algorithmic triage and clinical urgency; (2) adaptive decision-making: translating AI alerts into context-driven care; (3) emotional labour and psychological boundary management under continuous digital traceability; and (4) value reassessment and professional identity reconstruction in the digital emergency department. Nurses' ethical competence emerged as a dynamic, contextually embedded process, with digital reflective practices serving as a key scaffold for resilience and meaning-making. CONCLUSIONS: Digital health integration does not erode the core professional principles of emergency nursing; rather, it reconfigures and intensifies ethical negotiation across frequent micro-ethical moments. To sustain nurses' moral agency, digital systems must be redesigned to accommodate clinical friction rather than eliminate it, and nursing curricula must cultivate "digital moral resilience" to help nurses navigate the emotional toll of algorithmic management.