Constrained moral agency, distress, and residue in Neonatal Intensive Care nurses

Background Nurses in neonatal intensive care units (NICUs) play a pivotal role in managing ethically complex care for infants at the threshold of viability. However, institutional hierarchies, policies, and relational dynamics may constrain nurses’ ability to voice concerns and influence decisions, contributing to moral distress and moral residue. Aim To explore how NICU nurses experience and enact moral agency under constraint during threshold-of-viability decision-making, and how these experiences shape moral distress and moral residue. Research design Hermeneutic phenomenological study, reported in accordance with COREQ guidelines. Setting/Participants A purposive maximum-variation sample of 28 registered nurses (≥12 months of NICU experience) was recruited from four Level III NICUs in one administrative region of the country. Methods Semi-structured interviews were conducted remotely via videoconferencing in Arabic or English, audio-recorded, and transcribed verbatim. Arabic transcripts were translated and verified through back-translation to ensure semantic and conceptual equivalence. Data were analysed using hermeneutic phenomenological thematic analysis, supported by NVivo. Ethical considerations Ethical approval was obtained from the relevant university institutional review board and participating clinical sites. Written informed consent was obtained, and confidentiality was ensured through pseudonymization and secure data management. Findings Four themes captured nurses’ ethical experience: (1) Navigating the Grey Zone: The Weight of Ambiguity; (2) Voiceless at the Bedside: Structural Constraints on Moral Agency; (3) The Insider–Outsider Paradox: Peripheral Participation in Ethical Deliberation; and (4) The Lingering Echo: Moral Residue and Its Professional Toll. Conclusions Nurses’ moral distress at the threshold of viability was closely linked to constrained moral agency in hierarchical, policy-bound decision-making environments. Strengthening nursing inclusion in ethical deliberation and embedding structured post-case debriefing are plausible organisational strategies to reduce cumulative moral residue.