Proactive Nursing for Medication Safety: An Interpretative Phenomenological Study of Neonatal Intensive Care Nurses'...

Medication errors are frequent in Neonatal Intensive Care Units, where complex weight-based dosing and fragile physiology amplify the consequences of mistakes. Nurse-initiated medication queries function as a critical yet vulnerable safety barrier, but little is known about how neonatal intensive care nurses experience and navigate these decisions in everyday practice.

To explore how registered nurses in Neonatal Intensive Care Units experience and interpret initiating medication-safety queries during drug administration, and how they perceive individual, interpersonal and organisational-environmental conditions shaping these decisions.

Interpretative phenomenological study using Interpretative Phenomenological Analysis, rooted in Heideggerian hermeneutic philosophy and subsequently interpreted through the Human Factors Engineering lens. Purposive, maximum-variation sampling recruited neonatal intensive care nurses from three Saudi Arabian hospitals; 25 semi-structured interviews were conducted between February and May 2025 and analysed using a six-stage protocol supported by rigorous strategies for credibility and trustworthiness.

Interviews with 25 registered nurses yielded four interrelated experiential themes: (1) knowledge and confidence barriers-fear of appearing incompetent and uncertainty about calculations suppressed queries despite clinical experience; (2) interpersonal dynamics-physician approachability and peer support facilitated queries, whereas hierarchical norms created communication barriers; (3) organisational and system pressures-high workloads and a blame culture discouraged queries, while supportive policies and a strong safety climate empowered nurses and (4) moral and professional tensions-nurses experienced ethical conflict as they balanced patient advocacy with maintaining collegial relationships.

Nurse-initiated medication queries in Neonatal Intensive Care Units are not simply a function of individual vigilance or technological support. Sustained medication safety requires integrated interventions that strengthen nurses' clinical self-efficacy, reduce obstructive hierarchies, redesign workload and escalation pathways and explicitly address the moral distress arising when safety concerns are voiced or suppressed.

For critical care nurses working in Neonatal Intensive Care Units, nurse-initiated medication queries are a key, yet fragile, safety barrier. Findings underscore the need for organisations to combine electronic decision-support with assertiveness and communication training, NICU-specific workload optimisation, and ethically oriented debriefing and supervision. System-level changes targeting safety culture and hierarchical barriers are essential to sustaining proactive medication safety behaviours among NICU nurses.