Moral leadership in neonatal nursing: a qualitative narrative study of ethical decision-making in NICUs

Neonatal intensive care units (NICUs) concentrate ethically complex decision-making, yet the leadership behaviours supporting nurses' ethical agency remain insufficiently understood, particularly outside Western contexts.

To explore how moral leadership is experienced and enacted in shaping ethical decision-making among NICU nurses.

Qualitative narrative inquiry, reported in accordance with COREQ and SRQR.

Twenty-four registered nurses were recruited through purposive maximum-variation sampling across four Level III NICUs in northern Saudi Arabia. Narrative interviews (52-97 min; mean ≈ 74 min) were conducted over an eight-month period, from June 2025 to January 2026, and analysed using a narrative analysis approach integrating thematic and structural elements. Trustworthiness was supported through participant review of narrative summaries (14 of 24 participants provided substantive feedback), peer debriefing, reflexive journaling, and inter-coder agreement (κ = 0.83).

Five themes and 15 subthemes were identified. Moral recognition was narrated as active, affectively mediated, and culturally embedded. A recurrent gap between moral judgment and moral action was attributed to hierarchical suppression of nursing voice and limited psychological safety. Servant leadership behaviours, empathic listening, moral mentoring, and ethical role modelling, as cumulative relational formation, functioned as moral scaffolding enabling ethical voice and action. Three emergent subthemes extended the framework: ethical role modelling as identity-level formation, spiritually grounded motivation rooted in Islamic accountability, and culturally sanctioned disclosure silence as a source of moral dissonance.

Moral leadership in Saudi NICUs is a relational, contextually conditioned practice shaped by leadership behaviours, institutional structures, and cultural frameworks. Strengthening ethical infrastructure through leadership development, nurse-accessible ethics support, and competency frameworks embedding moral leadership as a professional standard is a priority for neonatal nursing in Saudi Arabia and comparable settings.

Not applicable.