Proactive Nursing for Medication Safety: An Interpretative Phenomenological Study of Neonatal Intensive Care Nurses' Experiences of Initiating Medication Queries

BACKGROUND: Medication errors are frequent in Neonatal Intensive Care Units, where complex weight-based dosing and fragile physiology amplify the consequences of mistakes. Nurse-initiated medication queries function as a critical yet vulnerable safety barrier, but little is known about how neonatal intensive care nurses experience and navigate these decisions in everyday practice. AIM: To explore how registered nurses in Neonatal Intensive Care Units experience and interpret initiating medication-safety queries during drug administration, and how they perceive individual, interpersonal and organisational-environmental conditions shaping these decisions. STUDY DESIGN: Interpretative phenomenological study using Interpretative Phenomenological Analysis, rooted in Heideggerian hermeneutic philosophy and subsequently interpreted through the Human Factors Engineering lens. Purposive, maximum-variation sampling recruited neonatal intensive care nurses from three Saudi Arabian hospitals; 25 semi-structured interviews were conducted between February and May 2025 and analysed using a six-stage protocol supported by rigorous strategies for credibility and trustworthiness. FINDINGS: Interviews with 25 registered nurses yielded four interrelated experiential themes: (1) knowledge and confidence barriers-fear of appearing incompetent and uncertainty about calculations suppressed queries despite clinical experience; (2) interpersonal dynamics-physician approachability and peer support facilitated queries, whereas hierarchical norms created communication barriers; (3) organisational and system pressures-high workloads and a blame culture discouraged queries, while supportive policies and a strong safety climate empowered nurses and (4) moral and professional tensions-nurses experienced ethical conflict as they balanced patient advocacy with maintaining collegial relationships. CONCLUSIONS: Nurse-initiated medication queries in Neonatal Intensive Care Units are not simply a function of individual vigilance or technological support. Sustained medication safety requires integrated interventions that strengthen nurses' clinical self-efficacy, reduce obstructive hierarchies, redesign workload and escalation pathways and explicitly address the moral distress arising when safety concerns are voiced or suppressed. RELEVANCE TO CLINICAL PRACTICE: For critical care nurses working in Neonatal Intensive Care Units, nurse-initiated medication queries are a key, yet fragile, safety barrier. Findings underscore the need for organisations to combine electronic decision-support with assertiveness and communication training, NICU-specific workload optimisation, and ethically oriented debriefing and supervision. System-level changes targeting safety culture and hierarchical barriers are essential to sustaining proactive medication safety behaviours among NICU nurses.