Nursing dying people in an acute hospital: A focused ethnography

BACKGROUND: Hospitals are the most common place of death worldwide yet dying patients' needs are frequently unmet. Acute wards are oriented toward cure, efficiency and discharge, creating conditions in which recognition of dying and transitions to comfort-focused care are often delayed. Nurses are central to end-of-life care but face moral, cultural and institutional constraints that shape how they can respond. RESEARCH QUESTION: How does the culture of the acute hospital setting shape how nurses manage the transition to comfort-focused care for dying people? DESIGN: Focused ethnography, underpinned by a constructionist paradigm. SETTINGS: Two acute medical wards (respiratory and gastroenterology) in a UK National Health Service (NHS) district general hospital in Southeast England. PARTICIPANTS: Twenty registered nurses with varied levels of seniority and experience, the majority internationally educated. METHODS: Data were collected over 23 weeks between January and June 2023 through 144 h of observation (32 episodes) and 20 semi-structured interviews. Analysis followed Roper and Shapira's ethnographic framework, with reflexivity maintained throughout. RESULTS: Six themes were identified: Denial, Competing Priorities, Discomfort, Moral Dissonance, Nurses' Agency and Delay, capturing how ward culture and institutional priorities shaped care. Denial described euphemistic language and relocation of dying patients that reduced visibility of death. Competing Priorities showed how task-driven routines and narratives of busyness displaced person-centred care. Discomfort reflected emotional unease, cultural differences and low confidence in end-of-life care. Moral Dissonance captured tensions between professional values and practice, with rituals offering moments of meaning. Nurses' Agency highlighted nurses' limited influence in decision-making. Delay described late recognition of dying and abrupt transitions, sometimes occurring only hours before death. Across these themes, dying patients were marginalised within systems prioritising cure and efficiency. CONCLUSION: Transitions to comfort-focused care in acute hospitals are shaped by denial, task orientation, prognostic uncertainty and hierarchical decision-making, which collectively delay recognition of dying. Internationally educated nurses experienced heightened discomfort due to cultural differences. Supporting nurses through empowerment, support for a culturally diverse workforce and structures that prioritise person-centred care is essential to mitigating moral distress and improving the quality of hospital end-of-life care. Organisational cultures must reorient toward person-centred approaches, fostering a culture where dying is acknowledged as part of care rather than an interruption to it. STUDY REGISTRATION: Not applicable (qualitative study, not a registered trial).