Moral responsibility, constrained authority: Neonatal nurses navigating periviable shared decision-making

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BackgroundShared decision-making at the threshold of viability is one of the most ethically complex areas of neonatal practice. For neonatal nurses, involvement is shaped by uncertainty, infant suffering, parental vulnerability, hierarchy, and enduring moral responsibility.AimTo explore neonatal nurses' experiences of shared decision-making with families of periviable infants in Level III neonatal intensive care units, with particular attention to ethical tensions, moral responsibilities, and practice-based challenges.Research designA qualitative Interpretative Phenomenological Analysis study informed by relational ethics. Data were generated through individual semi-structured, in-depth interviews, which were audio-recorded, transcribed verbatim, and analysed ideographically using Interpretative Phenomenological Analysis.Participants and research contextTwelve registered neonatal nurses were purposively recruited from four Level III neonatal intensive care units in one administrative region of Saudi Arabia. All had direct experience caring for periviable infants and participating in decision-making about life-sustaining treatment.Ethical considerationsEthical approval was obtained from the Jouf University Institutional Review Board and the relevant committees of the participating hospitals. Participation was voluntary; written informed consent was obtained; and confidentiality and potential power imbalances were carefully managed.FindingsFour superordinate themes were developed: living at the edge of uncertainty and bearing witness to suffering; being morally responsible but not fully authorised; holding families through fractured decision-making; and negotiating ethical practice within institutional and cultural worlds. Nurses described periviable shared decision-making as an ethically complex practice in which uncertainty, constrained authority, relational labour, and moral residue were continuously negotiated.ConclusionsNeonatal nurses occupy a central but often insufficiently recognised ethical position in periviable shared decision-making. Ethical practice at the threshold of viability requires structures that recognise nurses' moral agency, relational work, and ongoing responsibility within interprofessional decision-making and its aftermath.