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

Abstract

Background

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.

Aim

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

Design

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

Methods

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).

Results

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.

Conclusion

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.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-04918-z.

Introduction

Neonatal intensive care units (NICUs) represent one of the most morally demanding clinical environments in contemporary healthcare, where nurses confront life-and-death decisions with alarming frequency and limited ethical infrastructure [1–3]. The intersection of technological advancement, parental vulnerability, and diagnostic uncertainty creates a clinical landscape in which ethical dilemmas are not occasional disruptions but constitute the very fabric of daily practice [4–6]. Despite the growing recognition that moral dimensions of nursing practice influence clinical outcomes, workforce sustainability, and the quality of family-centred care, the specific leadership behaviours that guide nurses through these ethical crucibles remain insufficiently understood [7–10]. In this paper, the terms ‘moral’ and ‘ethical’ are used largely interchangeably to denote questions of right action, values, and obligation in clinical care, consistent with their overlapping usage in the nursing ethics literature; where an analytic distinction is drawn, ‘moral’ foregrounds the personal, agentic, and affective dimensions of right action, whereas ‘ethical’ foregrounds principled or normative reasoning and institutional standards.

Internationally, the World Health Organisation and the International Council of Nurses have underscored the imperative to develop leadership models that integrate ethical reasoning into clinical governance structures, particularly in high-acuity paediatric settings [11, 12]. Nevertheless, dominant leadership paradigms in nursing continue to privilege operational efficiency and hierarchical decision-making over moral engagement. This disconnect is especially consequential in neonatal care, where decisions regarding treatment escalation, palliation, and parental involvement carry profound moral weight that extends beyond the confines of clinical protocols [13].

Background

Moral leadership in nursing is the ethical exercise of influence in practice through moral attentiveness, principled judgment, advocacy, and accountability. Unlike leadership models centred primarily on efficiency or authority, moral leadership prioritises nurses’ ethical agency in clinical decision-making [14, 15]. This focus is particularly important in neonatal intensive care units (NICUs), where nurses work amid prognostic uncertainty, high treatment intensity, and emotionally charged family interactions. Ethical decision-making in NICUs is a dynamic cognitive, emotional, and relational process [16]. Nurses must interpret uncertain clinical trajectories, weigh competing values, communicate concerns across professional hierarchies, and support families during morally consequential choices [17]. In this environment, ethical practice is shaped not only by individual competence but also by team communication patterns, leadership responsiveness, and organisational norms for ethical deliberation [18, 19].

Current evidence consistently shows that NICU nurses face a substantial moral burden, especially when they perceive a gap between what ought to be done and what is organisationally possible [20]. A persistent moral burden is associated with emotional exhaustion, reduced professional efficacy, lower job commitment, and increased turnover risk [21]. These outcomes are critical in neonatal care, where continuity of expert nursing support affects safety, developmental outcomes, and family trust [22]. Accordingly, moral leadership is not a peripheral ideal; it is a core determinant of the quality of care and workforce sustainability. The unit’s ethical climate further conditions nurses’ moral agency. When nurses experience psychological safety, meaningful interprofessional dialogue, and leadership validation of ethical concerns, they are more likely to speak up, advocate effectively, and participate in shared decision-making [23, 24]. When communication is constrained by hierarchy or defensive culture, ethically relevant nursing perspectives are less likely to shape decisions. In high-acuity neonatal settings, this difference can influence both clinical and relational outcomes [25].

Despite growing scholarship, three gaps remain. First, much of the literature is cross-sectional and prevalence-focused, describing moral distress more than explaining how ethical decision-making unfolds in practice [26]. Second, neonatal leadership research has emphasised operational and managerial domains, with limited analysis of bedside moral leadership behaviours [27]. Third, evidence is concentrated in a narrow range of health systems, limiting contextual transferability to settings with different sociocultural norms, family roles, and governance structures [28]. These limitations reduce practical translation. Without process-level understanding of how nurses move from moral recognition to moral action under constraint, organisations cannot design targeted supports for ethical practice [29]. Likewise, education and leadership development cannot fully prepare NICU nurses if moral competencies are inferred from outcomes alone rather than grounded in situated clinical narratives [30].

Addressing this gap is significant across practice, workforce, education, and policy. A stronger evidence base on moral leadership can inform ethically responsive care models and improve nurse–family communication. It can also support retention by protecting moral integrity and guiding competency frameworks that embed ethical leadership in neonatal nursing standards. This rationale underscores the need for rigorous qualitative inquiry into how NICU nurses enact moral leadership in ethical decision-making within everyday care.

The study

Aim of the study

The aim of this study was to explore the nature and enactment of moral leadership in shaping ethical decision-making practices among nurses working in neonatal intensive care units.

Research question

The primary research question guiding this study was: How do neonatal nurses experience and narrate the role of moral leadership in their ethical decision-making within NICU practice?

Objectives

To address the research question, the following objectives were established:

1. To describe how neonatal nurses identify and interpret morally complex situations encountered in daily NICU practice.

2. To explore the leadership behaviours, values, and relational practices that neonatal nurses perceive as supportive of ethical decision-making.

3. To analyse the narrative structures through which nurses construct meaning around moral agency, leadership influence, and ethical outcomes.

4. To identify the contextual, organisational, and interpersonal factors that facilitate or constrain moral leadership in neonatal care settings.

In synthesis, while the moral complexities of NICU nursing are well documented, the leadership dimensions that shape how nurses navigate these ethical terrains remain underexplored, particularly through qualitative approaches that can capture the temporal, contextual, and subjective aspects of moral experience. This study responds to the identified gap by employing a qualitative narrative design to illuminate the intersection of moral leadership and ethical decision-making from the perspective of practising neonatal nurses. Such an approach is timely given the international emphasis on strengthening ethical governance in high-acuity care environments and the pressing need for leadership models grounded in the moral realities of clinical practice.

Theoretical framework

This study is guided by an integrated framework combining Rest’s Four-Component Model of Moral Behaviour [31] with Servant Leadership Theory [32] to explain ethical decision-making among NICU nurses. Rest’s model conceptualises nurse moral processing as four interrelated components: moral sensitivity, moral judgement, moral motivation, and moral character. Together, these components represent how nurses recognise ethical issues, evaluate options, prioritise moral values, and translate ethical intent into action in high-acuity neonatal care [33]. Servant Leadership Theory provides the relational and organisational mechanisms that enable this moral process in practice [34]. For the purposes of this study, moral leadership is operationalised as the ethical exercise of influence in clinical practice through moral attentiveness, principled judgment, advocacy, and accountability, enacted by nurses and leaders who prioritise ethical agency and relational integrity in high-stakes care environments. This operationalisation is conceptually distinct from servant leadership, the theoretical mechanism by which moral leadership is enacted within this framework. Specifically, servant leadership is operationalised through empathic listening, moral mentoring, ethical role modelling, and empowerment. These mechanisms support ethical voice, principled deliberation, and morally accountable action, particularly in complex and hierarchical clinical environments. Moral leadership thus represents the overarching ethical orientation, while servant leadership behaviours constitute the relational and interactional means by which this orientation is made actionable in NICU practice.

As presented in Fig. 1, the framework comprises three interacting layers. The core layer is nurse moral processing (Rest’s four components). The middle layer is servant leadership mechanisms that influence and reinforce moral processing through cyclical pathways. The outer layer is the NICU contextual ecology, including ethical climate, interprofessional dynamics, institutional policy, and family engagement. Bidirectional arrows indicate reciprocal influence across layers: context shapes leadership enactment and nurse moral agency, while repeated ethically grounded practice can gradually influence local norms and decision environments. This framework informed the study’s aim, interview domains, and analytic interpretation by positioning moral leadership as the central mechanism linking NICU context to ethical decision-making outcomes.

Fig. 1.

Integrated framework for ethical decision-making in NICU nursing

Materials and methods

Research design

A qualitative narrative inquiry design was employed, guided by Clandinin and Connelly’s narrative inquiry tradition, as elaborated by Kim [35]. This design was selected because ethical decision-making in NICU practice is processual and relational, unfolding over time within institutional and sociocultural contexts; categorical or cross-sectional approaches are less suited to capturing these dynamics. Narrative inquiry preserves temporal sequence and contextual specificity while supporting systematic cross-narrative interpretation, making it epistemologically congruent with the study aim, particularly in morally complex high-acuity neonatal care. The study prioritises analytic transferability rather than statistical generalizability through depth, contextual richness, and multi-site variation. Reporting followed COREQ and SRQR standards [36, 37], with core COREQ domains (research team/reflexivity, study design, and analysis/reporting) addressed prospectively; completed checklists are provided in Supplementary File S2.

Setting and sampling

Study setting

The study was conducted across four Level III NICUs (Hospitals A–D) in the Al-Jouf region of Saudi Arabia, where care for critically ill and extremely preterm neonates concentrates ethically complex decision-making. Site descriptors were intentionally generalised to preserve institutional anonymity within a geographically bounded regional network. Multi-site recruitment introduced contextual variation in organisational culture, leadership structure, and staffing configuration. The Al-Jouf context also has sociocultural relevance: family-centred care is shaped by Islamic ethical frameworks, tribal family structures, and gendered professional norms that differ from those in many Western contexts, where evidence on NICU moral leadership has predominantly been produced.

Sampling strategy and eligibility

Purposive maximum-variation sampling was used. Variation was operationalised across five dimensions: NICU experience (2 to > 15 years), role (bedside nurse, charge nurse, clinical educator, nurse manager), gender, educational qualification (diploma to postgraduate), and site. Nurse managers distributed study information, while interested nurses contacted the research team directly to minimise perceived coercion. A secondary snowball strategy was used to identify information-rich cases; all nominations were screened against the same variation criteria to limit homogeneity in referrals.

Inclusion criteria were

(1) registered nurse employed in a Level III NICU at one of the four sites; (2) ≥ 2 years of continuous neonatal experience; (3) willingness to participate in an audio-recorded narrative interview; and (4) sufficient Arabic or English proficiency for substantive participation.

Exclusion criteria were

(1) extended leave at recruitment; (2) < 2 years of neonatal experience; and (3) current formal disciplinary review.

Sample size and narrative sufficiency

Twenty-four nurses were interviewed (Hospital A, n = 7; B, n = 6; C, n = 6; D, n = 5). In narrative inquiry, sample adequacy is determined by narrative sufficiency (i.e., interpretive completeness and conceptual depth) rather than by statistical power. Recruitment closure occurred when three consecutive interviews, reviewed through concurrent analysis, did not materially extend emergent narrative dimensions; this served as a pragmatic stopping aid, while the primary criterion remained interpretive completeness across the five variation dimensions. This approach is consistent with contemporary guidance on qualitative sufficiency [38]. Sample adequacy was further assessed using information power, considering aim specificity, theoretical relevance, narrative depth, and analytic strategy, and was judged sufficient for credible and transferable interpretation. Participant flow is provided in Supplementary Figure S1, and Participant characteristics are reported in the Results (Sect. "Overview of participants").

Research team

Data were collected by the principal investigator (PI), a PhD-prepared nurse academic and assistant professor in paediatric nursing with advanced training in qualitative methods and prior clinical experience in neonatal care. The secondary coder was a PhD-prepared nurse researcher with qualitative expertise who was independent of the core study team. Translation support was provided by a bilingual research assistant with a nursing background. No member of the research team held a supervisory or evaluative role over participants, and no pre-existing dependent relationship with participants was present at recruitment. The PI’s positionality as an insider to neonatal nursing culture and an institutional affiliate in the Al-Jouf region was managed through the structured reflexivity procedures described in Sect.  "Procedure".

Data collection

Instrument development

In-depth, semi-structured narrative interviews were the sole data-collection method, consistent with narrative inquiry’s emphasis on participant-generated, storied accounts. The interview guide was developed in three stages: (1) a structured review of NICU ethics and nursing leadership interview literature; (2) deductive mapping of draft prompts to the integrated theoretical framework (Rest’s Four-Component Model and Servant Leadership Theory); and (3) expert review by two nursing academics with qualitative and neonatal expertise, followed by cognitive interviewing with three NICU nurses external to the study. Iterative revisions were made after each stage. The final interview guide is provided in Supplementary File S1.

The guide included three sections. The opening used a grand-tour narrative prompt asking participants to recount a significant ethical challenge in NICU practice (what occurred, how they responded, and how they interpreted the experience) to elicit participant-led narrative structure. The term “ethical challenge” was used in the interview guide as an inclusive, participant-accessible construct encompassing any clinical situation perceived to involve competing values, uncertain moral obligations, or tension between professional duty and contextual constraint, thereby covering what the theoretical literature variously terms moral dilemmas, moral distress-producing situations, or ethically complex encounters. This inclusive framing was deliberate: it avoided imposing theoretical distinctions between “ethical” and “moral” challenges at the point of elicitation, allowing participants to define and narrate the experiences they considered morally significant, with theoretical categorisation applied at the analytic stage. The middle section employed theoretically informed probes addressing moral sensitivity, moral judgment, moral motivation, and moral character, as well as relational leadership dimensions (empathic listening, mentoring, role modelling, and empowerment). The closing section invited reflection on contextual and institutional influences on ethical decision-making. Non-directive depth probes (e.g., “Can you tell me more about that?”) were used to extend narrative detail without imposing interviewer framing.

Interview conduct

All interviews were conducted by the PI in private rooms within participating hospitals. Participants chose their preferred interview language (Arabic or English), with most interviews conducted in Arabic. Interviews lasted 52–97 min (mean ≈ 74 min), were audio-recorded with explicit consent, and were conducted once per participant (no repeat interviews). Participants were reminded that they could decline any question or pause/stop the interview at any time. Immediately after each interview, the PI completed field notes documenting interview context, interactional observations, and preliminary interpretive reflections, which were incorporated into the reflexive audit trail.

Procedure

Recruitment flow and data collection sequence

Following ethical approvals, the PI held briefing sessions with nurse managers at each site, and study information was distributed in staff areas. Overall, 41 nurses received study information, 31 met eligibility criteria, 26 provided consent, and 24 completed interviews (two withdrew before scheduling). Eligibility was confirmed using a brief pre-interview checklist. Participants recruited through either direct response or snowball nomination were screened against the same eligibility criteria and maximum-variation targets. Data collection proceeded sequentially across the four sites between June 2025 and January 2026 (eight months), enabling concurrent preliminary analysis between phases. Before interviewing at each site, the PI conducted two familiarisation visits to understand local workflow and team context; these visits informed interpretation but were not treated as formal observational data.

Transcription and translation

Arabic interviews were transcribed verbatim by a professional transcription service under a signed confidentiality agreement and were verified by the PI against the audio recordings. Transcripts were translated into English by a bilingual research assistant with a nursing background. Back-translation was conducted for a 30% random subsample; discrepancies were resolved through PI–translator consensus. Arabic originals were retained as the primary reference texts during analysis: coding was performed on English versions with iterative consultation of Arabic transcripts to preserve semantic and cultural nuance. Culturally specific terms lacking direct English equivalents were retained in Arabic with explanatory annotations. Quotations selected for publication were validated bilingually by the PI and research assistant.

Researcher reflexivity

The PI maintained a structured reflexive journal after each interview and analytic session, documenting (1) positional reflexivity (professional neonatal background and regional affiliation), (2) relational reflexivity (interviewer–participant dynamics, perceived hierarchy, and emotional tone), and (3) analytic reflexivity (evolving assumptions and interpretive uncertainty). In this narrative design, reflexivity was treated as ongoing critical self-interrogation rather than suppression of the researcher’s perspective. Reflexive entries were discussed with the research team and external peer debriefers to maintain transparency and analytic accountability. Reflexive memos were incorporated into the audit trail [39, 40].

Ethical considerations

Ethical approval was obtained from the Jouf University Institutional Review Board (IRB reference: 7602) and ratified by the ethics committees of all four participating hospitals before recruitment commenced. The study was conducted in accordance with the Declaration of Helsinki and the Saudi National Committee of Bioethics guidelines. Informed consent was treated as an ongoing process rather than a single administrative event. Participants received bilingual (Arabic/English) information sheets at least 72 h before the interview, and written consent was obtained immediately prior to data collection. Participants were informed of their right to decline any question, to pause or stop recording, and to withdraw their data within two weeks of the interview (before final dataset lock), a safeguard particularly relevant in narrative interviewing, where unanticipated personal disclosures may emerge. Participation or non-participation had no effect on employment status, appraisal, or professional standing.

Because interview content could include neonatal death, moral distress, and professional conflict, a psychological safety protocol was implemented, including referral pathways to occupational health and psychological support services at each institution. One interview was temporarily paused at the participant’s request and then resumed; no termination of the interview was required. Participants were pseudonymized using unique alphanumeric identifiers (P01–P24). Audio files and transcripts were stored on an encrypted, password-protected institutional server with access restricted to the research team. The linkage key was stored separately in a restricted-access file. Data retention and deletion (five years post-publication) were in accordance with institutional data governance policy.

Data analysis

Analytic approach and coding

Data were analysed using Riessman’s narrative analysis framework, integrating thematic narrative analysis with structural analysis to examine both cross-narrative patterning and the organisational form of individual stories as meaning-bearing in their own right. Coding and data management were conducted in NVivo 14, which supported data organisation, retrieval, cross-case querying, and audit trail documentation; all analytic and interpretive decisions were made by the research team. Analysis proceeded in three phases [41, 42].

Phase 1 (narrative organisation)

each transcript was read repeatedly in full, with marginal annotations used to identify story boundaries, temporal arc, and structural features (guided by Labov’s narrative grammar as a heuristic), preserving narrative integrity prior to formal coding [43].

Phase 2 (thematic coding)

a hybrid inductive–deductive strategy was applied. Deductive codes, derived from the integrated framework, were treated as provisional sensitising categories rather than exhaustive taxonomies; inductive evidence could revise, expand, or supersede them. Inductive line-by-line coding captured unanticipated narrative content. The coding unit was the narrative meaning segment (a coherent experiential episode rather than an isolated sentence) [44].

Phase 3 (theme integration)

candidate themes were iteratively refined through constant comparison and evaluated for internal coherence, external differentiation, analytic significance, and theoretical resonance. Theme labels were retained in participant-near language where feasible. Final themes were mapped to framework layers, and data not accommodated by existing components were retained as emergent theoretical contributions. Disconfirming cases were actively examined during theme refinement [45].

Inter-coder consistency

A secondary independent coder analysed a 25% random subsample (n = 6 transcripts) using the preliminary codebook. Cohen’s kappa was used as a pragmatic procedural consistency check, not as evidence of singular objective meaning (which would be epistemologically incongruent with narrative inquiry). Kappa was calculated at the narrative-segment coding level and supplemented by reflexive consensus dialogue and documented codebook revision to preserve interpretive nuance. The pre-specified target was κ ≥ 0.80. Initial agreement was κ = 0.76. Structured consensus meetings reviewed divergent coding decisions against the source text, followed by code-boundary refinement and recoding, yielding final agreement (κ = 0.83). All revisions and consensus decisions were documented in the audit trail.

Trustworthiness

Trustworthiness was established using Lincoln and Guba’s criteria [46, 47]. Credibility was supported through prolonged engagement, participant review of narrative summaries, peer debriefing, and reflexive triangulation. Narrative summaries were returned to all participants (24/24); 14 provided substantive feedback, including two minor contextual corrections that were incorporated. Non-response was treated as neutral rather than confirmatory. Four structured peer debriefing sessions were conducted with two external qualitative nursing researchers, and the debriefing records were retained [48, 49]. Each debriefing session served a distinct methodological function: Session 1 examined the appropriateness of the coding framework and whether sensitising categories were applied without premature closure; Session 2 reviewed the narrative analytic logic and identified potential gaps in thematic coverage; Session 3 interrogated emerging inductive themes and evaluated disconfirming cases; and Session 4 assessed the coherence and credibility of the final thematic structure and served as the confirmatory check informing the narrative sufficiency decision (P22–P24). Collectively, these sessions introduced an external perspective on interpretive decisions, challenged researcher assumptions, and produced documented evidence of analytic accountability, thereby strengthening credibility and confirmability. Dependability was supported by a comprehensive audit trail (method decisions, code evolution, reflexive entries, and consensus records) maintained in NVivo, along with a supplementary methodological log [50, 51]. Confirmability was reinforced through inter-coder consistency procedures, peer debriefing, reflexive journaling, and explicit documentation of positionality, thereby grounding interpretations in participant narratives [52, 53]. Transferability was addressed through thick description of context, participants, and data conditions; multi-site sampling across four hospitals broadened contextual range and supports applicability judgments in comparable neonatal and high-acuity settings, particularly in Middle Eastern and similarly structured health systems [54, 55].

Findings

Overview of participants

Twenty-four registered nurses completed in-depth narrative interviews across four Level III neonatal intensive care units (NICUs) (Hospitals A–D) in the Al-Jouf region of Saudi Arabia. The sample comprised 19 women (79.2%) and five men (20.8%), with continuous NICU experience ranging from 2 to 20 years (mean ≈ 8.9 years). Age data were not collected; participant heterogeneity was operationalised prospectively through role, years of NICU experience, educational qualification, gender, and site. Roles included bedside registered nurses (n = 13) and leadership/education roles comprising charge nurses (n = 4), clinical educators (n = 3), and nurse managers (n = 4), purposively recruited to ensure maximum variation across the pre-specified dimensions. Fourteen participants held a Bachelor of Science in Nursing (BSN), four held a Master of Science in Nursing (MSN), five held a nursing diploma, and one held a doctoral qualification. Full demographic and professional characteristics are presented in Table 1.

Table 1.

Demographic and professional characteristics of study participants (N = 24)

Characteristic	n (%) or value
Gender
Female	19 (79.2)
Male	5 (20.8)
Role
Bedside registered nurse	13 (54.2)
Charge nurse	4 (16.7)
Clinical educator	3 (12.5)
Nurse manager	4 (16.7)
Highest nursing qualification
Diploma	5 (20.8)
BSN	14 (58.3)
MSN	4 (16.7)
Doctoral qualification	1 (4.2)
Years of NICU experience	2–20 (mean ≈ 8.9)
Hospital site
Hospital A	7 (29.2)
Hospital B	6 (25.0)
Hospital C	6 (25.0)
Hospital D	5 (20.8)

Note. Hospitals are anonymised as A–D to preserve institutional confidentiality within a geographically bounded regional system. Experience reflects continuous years of NICU practice at the time of the interview

Across narratives, nurses situated ethical decision-making within a practice world shaped by Islamic ethical frameworks, family obligations, and hierarchical institutional structures. Interviews were conducted in Arabic or English; Arabic quotations were translated and bilingually validated, with minor edits applied where required to preserve meaning (Sect.  "Transcription and translation"). The narratives varied in register and form, ranging from reflective accounts to more immediate, fragmented retellings:

In this unit, you carry the baby, the family, and your own conscience all at once. There is no space in between. (P05, Hospital A, Bedside RN, 3 years experience)

I don’t know… the baby was stable, the numbers were fine, but something I kept going back. I couldn’t just leave the family there with that… it wasn’t clinical; that was the whole point… and it stayed with me. (P12, Hospital B, Bedside RN, 2 years experience)

Narrative sufficiency was judged to have been reached when three consecutive interviews (P22, P23, and P24, the final three participants interviewed, in sequence), reviewed during concurrent analysis, introduced no new thematic dimensions to the evolving codebook and memo log; this was confirmed through peer debriefing and documented in the audit trail.

Key themes identified

Thematic narrative analysis yielded five major themes comprising 15 subthemes. Themes were developed through a hybrid inductive–deductive process and evaluated for internal coherence, external differentiation, analytic significance, and theoretical resonance. Three subthemes (3.3, 4.2, and 5.3) were generated inductively and are designated as emergent contributions. Structural analysis indicated that many accounts followed a complication–evaluation–resolution arc, often ending with a coda that reflects the episode’s enduring moral significance, consistent with the analytic approach described in Sect.  "Analytic approach and coding". Disconfirming case narratives, in which leadership was absent, suppressive, or counterproductive, were retained and are represented within Themes 2 and 5. Table 2 presents the themes, subthemes, theoretical alignment, and correspondence to the study objectives. To orient the reader, each theme below opens by stating the study objective and theoretical component it addresses; each subtheme is illustrated by at least two participant narratives, and Table 2 maps every subtheme to its theoretical alignment and corresponding study objective.

Table 2.

Emergent themes and subthemes reflecting moral leadership and ethical decision-making in NICU nursing (N = 24)

Theme	Subthemes	Framework alignment and study objective(s)
Theme 1. Moral Recognition at the Threshold of Care	1.1 Recognising ethical weight in clinical ambiguity; 1.2 Emotional attunement as a primary moral signal; 1.3 Family presence and cultural complexity as catalysts for recognition	Rest: Moral Sensitivity; NICU ecology (Objective 1)
Theme 2. Deliberating Under Constraint: Ethical Judgment in Hierarchical NICU Environments	2.1 Deliberative reasoning amid prognostic uncertainty; 2.2 Hierarchical suppression of ethical voice; 2.3 Balancing family values and medical authority	Rest: Moral Judgment; Servant leadership (Empowerment); NICU ecology (Objectives 1, 2, 4)
Theme 3. Servant Leadership as Moral Scaffolding	3.1 Empathic listening as ethical legitimation; 3.2 Moral mentoring and guided ethical deliberation; 3.3 Ethical role modelling as relational moral formation (emergent)	Servant leadership mechanisms (Objective 2)
Theme 4. Moral Agency, Identity, and Sustained Motivation	4.1 Professional identity as ethical anchor; 4.2 Spiritually grounded moral motivation (emergent); 4.3 Moral courage and persistent ethical advocacy	Rest: Motivation/Character; NICU ecology (Objective 3)
Theme 5. Contextual Ecology of Ethical Practice	5.1 Ethical climate and psychological safety; 5.2 Institutional constraint and moral residue; 5.3 Cultural norms of disclosure and the ethics of silence (emergent)	NICU ecology domains (Objective 4)

Theme 1. Moral Recognition at the Threshold of Care

This theme describes how nurses identified morally complex situations as ethically distinct from routine clinical difficulty, directly addressing Objective 1 and aligning with moral sensitivity. Across accounts, recognition was narrated as an active process shaped by clinical experience, emotional responsiveness, and cultural attunement.

Subtheme 1.1: Recognising ethical weight in clinical ambiguity.

Eighteen participants described episodes in which they identified an ethical dimension before it was named or acknowledged by the broader team, commonly when prognostic uncertainty intersected with communication practices or perceived gaps in informed understanding.

I knew something was wrong, not medically… but wrong in a deeper sense. The family was not being told the truth about what the numbers meant for their baby’s future. I could feel it before I could name it. (P09, Hospital B, Charge Nurse, 13 years experience)

The team was talking about the next intervention as if it were purely technical. I kept thinking: Who is asking what this baby is going through? That recognition that this is an ethical question, not only a clinical one, came to me in the room, quietly. (P17, Hospital C, Nurse Manager, 20 years experience)

Subtheme 1.2: Emotional attunement as a primary moral signal.

Nurses described unease, distress, or a persistent sense of wrongness as salient cues that preceded and oriented subsequent reasoning, with more experienced participants reporting greater ability to interpret and act on these signals deliberately.

I call it the feeling before the thought. Something in my body, heaviness, a kind of stillness, tells me that what I am being asked to do is not right. I have learned to trust that feeling. (P06, Hospital A, Clinical Educator, 11 years experience)

When I felt sick inside during the family meeting… I knew I was witnessing something ethically important. Later, I understood it was because the family’s values were not being heard. But the feeling came first. (P14, Hospital C, Bedside RN, 8 years experience)

Subtheme 1.3: Family presence and cultural complexity as catalysts for recognition.

Eleven participants described family presence and culturally and religiously inflected understandings of life, death, and parental authority as intensifying moral attentiveness and introducing ethical complexity not readily addressed by protocols.

The father told us that withdrawing support was against God’s will. The doctors saw a clinical decision; he saw a religious obligation. I was in the middle; I had to recognise that both were real ethical positions. (P02, Hospital A, Charge Nurse, 12 years experience)

In our culture, the family does not always speak directly about death… If you are not attuned to this, culturally, not just clinically, you can miss the ethical dimension of what the family is expressing. (P16, Hospital C, Charge Nurse, 14 years experience)

Theme 2. Deliberating Under Constraint: Ethical Judgment in Hierarchical NICU Environments

This theme captures how ethical judgment was enacted within hierarchical, organisational, and interprofessional constraints, addressing Objectives 1, 2, and 4 and aligning with moral judgment and the contextual ecology. All participants described at least one episode in which deliberation was shaped, interrupted, or suppressed by institutional dynamics.

Subtheme 2.1: Deliberative reasoning amid prognostic uncertainty.

Ethical deliberation was described as most demanding under genuine uncertainty, when choices carried substantial consequences despite incomplete information.

You cannot wait for certainty in this unit. There is no certainty. You have to make an ethical judgment with incomplete information. (P04, Hospital A, Nurse Manager, 16 years experience)

I went through everything I knew, evidence, protocols, and what the family told us, and none of it gave me a clear answer. I had to sit with the uncertainty and still act. (P19, Hospital C, Clinical Educator, 9 years experience)

Subtheme 2.2: Hierarchical suppression of ethical voice.

Nineteen participants described dismissal, minimisation, or silencing of ethical concerns, particularly among bedside nurses. Narratives are frequently centred on attempted voice as the complication, followed by foreclosure and an unresolved coda.

I raised my concern three times… I was told clearly that the decision had been made. My voice, my judgment, did not exist in that room. (P10, Hospital B, Bedside RN, 6 years experience)

The culture here is that the doctor speaks and the nurse listens… When that voice is silenced, the ethical quality of the decision suffers. (P21, Hospital D, Charge Nurse, 11 years experience)

Subtheme 2.3: Balancing family values and medical authority.

Participants described occupying an informal mediating position between family values and medical authority, requiring active ethical judgment that is not reflected in formal role descriptions.

My job, not officially, but actually, was to stand between two sets of values and find a path that honoured both. (P13, Hospital B, Clinical Educator, 10 years experience)

I translated not language, but meaning… and sometimes I had to argue for it when no one asked me to. (P24, Hospital D, Bedside RN, 3 years experience)

Theme 3. Servant Leadership as Moral Scaffolding

This theme addresses Objective 2 by describing mechanisms of servant leadership that enabled ethical decision-making. Twenty-two participants reported at least one experience in which leadership behaviours supported ethical practice; 16 also described episodes of absent or withheld leadership as formative.

Subtheme 3.1: Empathic listening as ethical legitimation.

Being genuinely heard by a leader was described as legitimising moral concerns and transforming private burdens into shared responsibility.

My manager sat with me after that baby died… just to listen… That act told me my moral concern was real, and it mattered. (P08, Hospital B, Bedside RN, 4 years experience)

She always asked, ‘How are you with this decision?’… That one question changed how I understood my ethical responsibility. (P05, Hospital A, Bedside RN, 3 years experience)

Subtheme 3.2: Moral mentoring and guided ethical deliberation.

Participants described mentoring as guidance through questioning that strengthened moral reasoning rather than prescribing action.

She would ask: ‘What does your professional judgment tell you?’… She was teaching me to trust my own moral reasoning. (P01, Hospital A, Bedside RN, 9 years experience)

He gave me a method for thinking, not just an answer. (P07, Hospital A, Bedside RN, 7 years experience)

Subtheme 3.3: Ethical role modelling as relational moral formation (emergent).

Observing role models was described as a gradual, relationally formative process that shapes moral identity beyond discrete behavioural imitation, often recounted retrospectively over months or years.

It was not one thing she did; it was how she was in the room with difficult things… That presence became part of how I try to be. (P23, Hospital D, Nurse Manager, 15 years experience)

I learned more about what ethical practice looks like from watching her than from any course or policy. (P11, Hospital B, Nurse Manager, 18 years experience)

Theme 4. Moral Agency, Identity, and Sustained Motivation

This theme addresses Objective 3 by describing how nurses narrated moral agency as actively sustained under pressure. Subthemes 4.1 and 4.2 aligned with moral motivation, whereas 4.3 aligned with moral character, reflecting sustained ethical action despite resistance.

Subtheme 4.1: Professional identity as ethical anchor.

Professional identity operated as a stabilising moral reference point, particularly in narratives of resistance.

What kind of nurse am I… what does she do in this moment? That question is always there. It is the ground I stand on. (P16, Hospital C, Charge Nurse, 14 years experience)

If I do not speak for this baby, I have betrayed what it means to be what I am. (P12, Hospital B, Bedside RN, 2 years experience)

Subtheme 4.2: Spiritually grounded moral motivation (emergent).

Seventeen participants described the Islamic faith as an active moral framework that sustains ethical action and accountability beyond institutional recognition.

Every soul, even this 500-gram baby, has a dignity given by God that no protocol and no hierarchy can override. (P17, Hospital C, Nurse Manager, 20 years experience)

I will be accountable before God for what I did in that moment. That accountability does not sleep when I leave the hospital. (P04, Hospital A, Nurse Manager, 16 years experience)

Subtheme 4.3: Moral courage and persistent ethical advocacy.

Moral character was expressed as sustained advocacy across multiple attempts and routes, often despite social or professional risk.

I raised it in handover… again… then I documented it. Three times, three different routes… The baby could not speak. I had to. (P03, Hospital A, Bedside RN, 5 years experience)

I persisted… I was not popular for it. But I was right to persist. (P22, Hospital D, Bedside RN, 6 years experience)

Theme 5. Contextual Ecology of Ethical Practice

This theme addresses Objective 4 by describing contextual, organisational, and interpersonal conditions that shaped moral leadership and ethical decision-making. All participants identified contextual determinants of moral agency; 21 described specific organisational conditions that enabled or undermined ethical practice.

Subtheme 5.1: Ethical climate and psychological safety.

Participants described variation in ethical climate across sites. Psychological safety, defined as the freedom to raise concerns without reprisal, was repeatedly identified as a key enabler.

When something is ethically wrong, we say so… She made it safe to speak. That changes everything. (P06, Hospital A, Clinical Educator, 11 years experience)

In the other unit… you did not raise ethical questions… Here it is different. The climate permits honesty. (P20, Hospital D, Bedside RN, 4 years experience)

Subtheme 5.2: Institutional constraint and moral residue.

Understaffing, documentation burden, and lack of accessible ethics consultation were described as contributing to a cumulative unresolved ethical burden.

A small piece of that stays inside you… Over the years, it accumulates… The weight does not go away when you clock out. (P09, Hospital B, Charge Nurse, 13 years experience)

My options are: speak to the manager, document it, or carry it alone… The organisation has not built the infrastructure. (P11, Hospital B, Nurse Manager, 18 years experience)

Subtheme 5.3: Cultural norms of disclosure and the ethics of silence (emergent).

Thirteen participants described tension surrounding disclosure practices, in which withholding prognostic information, particularly from mothers, was, for some, framed as an expression of compassion. Nurses described moral dissonance when culturally endorsed silence constrained truthful communication and ethical advocacy.

I sat with her every day, and she was asking me questions I could not honestly answer… I was asked to maintain a silence I did not believe was right. (P15, Hospital C, Bedside RN, 3 years experience)

I was told it was cultural, not ethical. But I did not accept that distinction. (P18, Hospital C, Bedside RN, 5 years experience)

Narrative sufficiency was confirmed following three consecutive interviews (P22–P24) and peer debriefing session four, as tracked in the evolving codebook and memo log. The basis for this determination was threefold: (1) concurrent thematic analysis of P22, P23, and P24 identified no novel codes, emerging subthemes, or revisions to the existing codebook; (2) memo entries from this period documented convergent narrative content with no analytic surprises; and (3) peer debriefing session four independently reviewed the final thematic structure and concurred that interpretive completeness had been achieved across all five pre-specified variation dimensions (experience, role, gender, qualification, and site). This multi-indicator approach is consistent with Lincoln and Guba’s trustworthiness framework and contemporary guidance on qualitative sample adequacy [38, 46, 47]. Narrative summaries were returned to all participants; 14 provided substantive feedback, and two minor contextual corrections were incorporated prior to finalisation. Inter-coder agreement reached κ = 0.83 following structured consensus review.

Discussion

Interpretation of findings

This study provides a process-level account of how moral leadership is experienced and enacted in neonatal intensive care, yielding five themes and 15 subthemes that collectively address the four study objectives. Three findings warrant particular interpretive attention.

First, moral recognition was narrated as an active, affectively mediated process rather than a passive perceptual event. Nurses described emotional attunement, unease, distress, or a persistent sense of wrongness as an early and epistemically significant signal that an ethical dimension was present, preceding and orienting deliberation within individual episodes. Moral recognition was simultaneously culturally embedded: family presence and Islamic ethical frameworks shaped what nurses identified as ethically salient and how they interpreted their obligations within complex family–team interactions. This positions emotion as a constitutive component of moral sensitivity rather than as a distortion of it, and underscores that moral sensitivity in this setting is inseparable from cultural and relational contexts [56].

Second, the findings revealed a recurrent, structurally produced gap between moral judgment and moral action. Nineteen of 24 participants described situations in which ethical reasoning was well developed yet could not be translated into practice because hierarchical dynamics positioned decisions as medically owned and the nursing voice as procedurally illegitimate. This gap was not attributed to individual moral failure but to leadership and organisational conditions that either facilitated or foreclosed ethical speech. Participants framed hierarchical suppression as a direct pathway through which unresolved moral burden accumulated over time, reframing moral distress as a consequence of structural silencing rather than simply an individual emotional response. Importantly, while moral recognition could precede deliberation within a given episode, moral processing was not experienced as a fixed, linear sequence across the broader decision-making process; contextual constraints could interrupt the transition from judgment to action, regardless of the quality of reasoning achieved [57]. In this respect, several narratives illustrated not the active presence of moral leadership but its systemic absence: nurses frequently sustained individual moral agency precisely where organisational and systemic moral leadership were lacking. This reinforces that moral leadership is most consequential as a systemic and structural property of the unit rather than as an attribute left to individual initiative.

Third, spiritually grounded moral motivation emerged as the most contextually distinctive finding. Seventeen participants described Islamic faith as an active moral framework that provided accountability, conferred dignity on the neonate, and justified advocacy against institutional resistance operating independently of organisational recognition or professional consequence. Rather than functioning as background culture, faith operated as a practical and motivationally generative resource that sustained ethical commitment when institutional supports were weak or absent [58–60].

Integration with existing knowledge

The finding that nurses experience moral recognition as an affectively grounded, proactive process aligns with current views of moral sensitivity as relational and perceptual, shaped by clinical experience and situational attunement [61, 62]. The present study extends this understanding by specifying how cultural context, particularly Islamic frameworks around life, death, and family authority, inflects the triggers and content of recognition in ways that culturally neutral models may not capture.

The centrality of hierarchical suppression in constraining ethical voice is consistent with established evidence linking organisational silence and reduced psychological safety to constrained advocacy and increased moral burden in high-acuity nursing contexts [63]. This study advances that line of work by showing that psychological safety is experienced as leadership-mediated: it is built or dismantled through identifiable leadership behaviours and interactional practices rather than emerging spontaneously from “unit culture.” This distinction matters clinically because it moves intervention from broad culture-change rhetoric to specific, accountable leadership practice.

The servant leadership mechanisms identified here are consistent with evidence that leadership styles emphasising listening, mentoring, and ethical influence are associated with ethical climate and moral action. The contribution of this study is process-level specificity: it clarifies how moral scaffolding is enacted (or withheld) in real NICU encounters and how these micro-practices shape nurses’ capacity to deliberate and act ethically [64, 65].

Two inductive contributions extend existing conceptualisations in ways that are directly relevant to workforce development. First, ethical role modelling was experienced not merely as behavioural imitation but as cumulative, relational moral formation over time, an identity-shaping process that depends on sustained proximity and repeated observation of ethical practice under pressure. Second, culturally shaped norms of prognostic disclosure and protective silence were narrated not only as communication practices but as ethically consequential conditions that produced moral dissonance for nurses positioned as custodians of an ethically contested silence [66, 67].

Theoretical and practical implications

Theoretically, this study contributes to nursing ethics and leadership scholarship in three ways. It elaborates on nurse moral processing as affectively mediated, culturally inflected, and dynamically interactive rather than purely cognitive and sequential. It refines servant leadership by specifying how empathic listening and moral mentoring function as interactional practices that convert private moral concern into shared professional responsibility, and by identifying ethical role modelling as relational formation rather than discrete behavioural transmission. Finally, it highlights spiritually grounded moral accountability as a culturally anchored motivational pathway that warrants explicit consideration when applying moral leadership frameworks in Muslim-majority healthcare contexts [68].

For clinical practice, the findings identify leadership behaviours that function as an ethical infrastructure. Leaders who enact empathic listening (attending to how nurses are engaging with ethically difficult decisions) and who guide deliberation through structured questioning rather than prescriptive answers create conditions in which nurses can voice concerns, reason with support, and sustain advocacy without isolation. These behaviours are observable, trainable, and assessable; they should be treated as explicit leadership competencies rather than assumed interpersonal traits [69].

For nursing education, the findings suggest that ethics curricula in Saudi Arabia and analogous contexts should engage Islamic bioethical reasoning and faith-based accountability alongside professional ethics, not as cultural add-ons but as ethical resources that already shape motivation and justification for moral action. Education should also address the cumulative, unresolved moral weight over the course of careers, preparing nurses for chronic ethical burdens rather than focusing exclusively on resolving discrete dilemmas [70].

At the organisational level, the reported absence of nurse-accessible ethics consultation and structured ethical reflection pathways across sites represents a governance gap with tangible ethical costs. Institutions should establish nurse-accessible ethics support mechanisms, protected time for ethical debriefing, and clear escalation routes for ethical concerns, thereby expanding nurses’ options beyond speaking, documenting, or remaining silent. Psychological safety should be treated as an ethical governance priority supported by leadership accountability and monitored through routine assessment [71].

Strengths and limitations

Key strengths include a multi-site design across four Level III NICUs, maximum-variation sampling across five dimensions, and a narrative inquiry approach that captures the temporal, relational, and culturally situated nature of moral leadership. Rigour was strengthened through a hybrid inductive–deductive analytic strategy, structured trustworthiness procedures, inter-coder agreement following consensus processes, participant review of narrative summaries, peer debriefing, and a comprehensive audit trail. The translation workflow, including back-translation of a subsample and bilingual validation of quotations, supported semantic and cultural fidelity.

Several limitations should be acknowledged. The study was conducted in a single Saudi region, and transferability may vary across other regions or health systems with different governance structures, professional hierarchies, or family dynamics. Data were generated through single-timepoint interviews; leadership behaviours were captured as experienced and remembered rather than observed in real time, and change over time cannot be inferred. Nurses who had exited NICU practice were excluded, which may have led to an underrepresentation of more severe experiences of moral constraint. Despite rigorous translation procedures, culturally embedded spiritual and relational meanings may not be fully preserved across languages. Finally, age was not collected; while not central to the study aim, this limits examination of career-stage effects beyond years of NICU experience.

Recommendations and future research

Future research should extend this work in three directions. First, longitudinal narrative inquiry following the same participants over 12–24 months could examine how moral leadership experiences accumulate into moral residue or, conversely, how sustained servant leadership fosters moral resilience. Second, comparative qualitative studies across Saudi regions and other Muslim-majority contexts could test the transferability of spiritually grounded motivation and examine how Islamic ethical frameworks interact with different governance models and professional hierarchies. Third, intervention research should develop and evaluate a structured moral mentoring programme for charge nurses and nurse managers, grounded in the specific listening and guided deliberation behaviours identified here, and assess impacts on ethical voice, perceived psychological safety, and moral burden using mixed-methods evaluation.

Three practice recommendations follow directly from the findings. Healthcare institutions should establish nurse-accessible ethics consultation with clear escalation pathways and nursing representation. Leadership development should operationalise moral scaffolding competencies, empathic listening, structured moral mentoring, and sustained ethical role modelling through simulation-based training and formative assessment rather than generic communication modules. Finally, neonatal nursing competency frameworks should formally recognise moral leadership, ethical voice, and moral agency as core competencies supported through curriculum integration, assessment, and ongoing professional development.

Conclusion

This study demonstrates that moral leadership in Saudi Arabian NICUs is an enacted, relational, and contextually conditioned practice that shapes nurses’ capacity to recognise ethical concerns, deliberate under uncertainty, and sustain ethical action. Servant leadership behaviours, particularly empathic listening, moral mentoring, and ethical role modelling, experienced as a cumulative relational process, functioned as moral scaffolding that enabled translation of ethical intent into practice. Where these mechanisms were absent or withheld, hierarchical suppression of voice, institutional constraints, and culturally sanctioned silence contributed to unresolved moral burden and constrained ethical participation. Spiritually grounded moral motivation emerged as a constitutive and active resource for moral agency rather than a cultural backdrop, highlighting the need for culturally attuned approaches to moral leadership development in Muslim-majority healthcare contexts. The significance of these findings extends across four domains. Clinically, they identify specific, trainable leadership behaviours, empathic listening, guided moral deliberation, and ethical role modelling, that provide an empirically grounded basis to inform leadership development in neonatal settings.

For the workforce, the study reveals that psychological safety is leadership-mediated rather than organisationally ambient, offering a potential lever that may help support nurse retention and mitigate moral burden. For education, the findings affirm that Islamic bioethical reasoning and faith-based accountability must be integrated as substantive ethical resources in curricula serving Muslim-majority populations, not appended as cultural sensitivity modules. For policy, the consistent absence of nurse-accessible ethics consultation across four regional NICUs represents a structural gap that warrants focused governance attention. Strengthening NICU ethical infrastructure through targeted leadership development, nurse-accessible ethics support mechanisms, and competency frameworks that embed moral leadership as a professional standard is a clinically, organisationally, and ethically significant priority for neonatal nursing in Saudi Arabia and comparable settings globally.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1 ^{(612.6KB, pdf)}

Supplementary Material 2 ^{(612.7KB, pdf)}

Abbreviations

BSN

Bachelor of Science in Nursing

COREQ

Consolidated Criteria for Reporting Qualitative Research

IRB

Institutional Review Board

MSN

Master of Science in Nursing

NICU

Neonatal Intensive Care Unit

PI

Principal Investigator

RN

Registered Nurse

SRQR

Standards for Reporting Qualitative Research

Author contributions

M.M.A. conceived and designed the study, developed the data collection instruments, coordinated ethical approvals and institutional access, collected and managed the data, conducted the qualitative data analysis and analytic interpretation, and wrote, revised, and approved the final manuscript.

Funding

This work was funded by the Deanship of Graduate Studies and Scientific Research at Jouf University under grant No. (DGSSR-2025-01-01586).

Data availability

Owing to the qualitative nature of the study and the risk of deductive identification, interview transcripts and related materials are not publicly available. De-identified excerpts may be available from the corresponding author on reasonable request, subject to ethical and institutional approval.

Declarations

Ethics approval and consent to participate

The study was conducted in full accordance with the Declaration of Helsinki and the Saudi National Committee of Bioethics guidelines. Ethical approval was obtained from the Jouf University Institutional Review Board (IRB: 7602) and the ethics/administrative committees of the four participating hospitals. Written informed consent was obtained from all participants. Participation was voluntary, confidentiality was protected through pseudonymization, and study data were stored on encrypted, password-protected devices accessible only to the research team. A confidential counselling referral pathway was available but not used.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.