Neonatal nurses' moral agency in raising medication and treatment safety concerns in high-risk NICUs

BackgroundIn neonatal intensive care units (NICUs), nurses may recognise medication or treatment risk before others do. Raising a concern is an ethical act, but moral agency extends beyond voice behaviour.Research question/aim/objectivesHow do neonatal nurses experience and enact moral agency when raising medication and treatment concerns in high-risk NICUs? We examined risk recognition, enactment of voice, contextual influences, and responsibility after voice.Research designQualitative Interpretive Description with abductive thematic analysis informed by an author-constructed sensitising framework. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) and Standards for Reporting Qualitative Research (SRQR).Participants and research contextTwenty neonatal nurses with at least 12 months of NICU experience were purposively sampled across one Level III and two Level II NICUs in northern Saudi Arabia. Arabic- or English-language interviews conducted from June to December 2025 were analysed in NVivo.Ethical considerationsA university institutional review board approved the study; identifying approval details are withheld for double-anonymised review. Research-committee authorisation was subsequently obtained at each participating hospital. Written informed consent, confidential recruitment, de-identification, and an interview distress safeguard protected participants.Findings/resultsThe interpretive account was organised into four design-congruent themes: seeing risk before harm; deciding to speak; practising within hierarchy; and carrying responsibility beyond voice. Nurses described moral noticing, strategic advocacy, and persistence. Participants described perceived legitimacy as shaped by hierarchy, leadership responsiveness, and professional and sociocultural positioning. Responsibility continued after voice, while delayed or withheld voice left moral residue.ConclusionsMoral agency was relational and institutionally conditioned. Voice-supportive NICUs require credible escalation pathways, respectful responses, and visible closure of concerns. Post-voice responsibility was a prespecified domain; 'residual accountability' is offered as a provisional analytic label for prompted accounts within that domain, not as an unprompted emergent or established construct.