Osama Mohamed Elsayed Ramadan

Artificial intelligence–enhanced foetal monitoring is entering intrapartum care, yet little is known about how it reshapes the credibility of nursing knowledge, professional authority and relational practice. This interpretive description study explored how obstetric nurses negotiated clinical judgement, autonomy and woman‐centred care while working with an artificial intelligence–enhanced cardiotocography system in a physician‐led tertiary maternity service in Saudi Arabia. Semi‐structured interviews with 18 obstetric nurses, each with 6 months to 4 years' experience of the system, were analysed using reflexive thematic analysis sensitised by Cognitive Continuum Theory and the concept of epistemic injustice. Analysis showed that nurses read beyond the trace, negotiated autonomy under algorithmic surveillance and worked deliberately to keep the woman in view. Alerts often legitimised concerns nurses had already formed, functioning as institutional permission to escalate rather than clinical revelation. When judgement diverged from system output, nurses experienced asymmetric accountability and performed epistemic translation work, recasting embodied and relational knowledge into algorithm‐compatible language to secure recognition. Artificial intelligence–enhanced monitoring was therefore experienced as an epistemic and relational intervention, not merely decision support, that could reinforce established hierarchies of credibility. Whose knowledge counts during labour is thus a question of justice as much as safety. Trial Registration: Not applicable. This study was a qualitative interview study and did not involve a clinical trial.

Background: Vaccine hesitancy can generate moral distress when nurses’ duty to protect children conflicts with parental decision-making authority, family dignity, and longitudinal trust. Research question/aim/objectives: To interpret how primary health care nurses experience and negotiate moral distress during vaccine-hesitancy encounters with families in culturally diverse Saudi primary care. Research design: A qualitative Interpretive Description study informed by moral distress theory. In-person semi-structured interviews were analysed using reflexive thematic analysis. Participants: and research context: Twenty-two registered nurses from 20 primary health care centres in one southern Saudi health cluster participated. Purposive recruitment lacked a fixed sampling frame or approach log; therefore, a conventional response rate was not calculable. Ethical considerations: Najran University Research Ethics Committee approved the study, and the health cluster granted permission. Written informed consent, confidentiality, and voluntary participation were maintained. Findings/results: Participants’ retrospective accounts generated four themes: constrained action despite knowing what responsible practice required; moral agency negotiated through family, faith, and gendered authority; cumulative moral residue; and organisational ethical responsibility. Family decision hierarchy was the most consistently described cultural constraint, while religious interpretation and gendered credibility shaped particular encounters. Conclusions: Within this single-cluster sample, nurses’ moral distress was interpreted as a relationally and organisationally mediated ethical burden shaped by family hierarchy, religious reasoning, gendered credibility, and limited organisational support. Participant-informed ethics case forums, shared escalation pathways, and team-based support warrant local piloting and evaluation as potential strategies to support nurses’ moral voice while preserving respectful dialogue and longitudinal trust.

Background: In 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/objectives: How 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 design: Qualitative 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 context: Twenty 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 considerations: A 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/results: The 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. Conclusions: Moral 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.

Background: Artificial intelligence‐assisted early warning systems (AI‐EWS) are increasingly integrated into critical care, yet little is known about how nurses experience automation bias and negotiate professional autonomy when algorithmic recommendations intersect with bedside judgement. Aim: To explore how critical care nurses experience automation bias and negotiate professional autonomy when using AI‐EWS in intensive care. Study Design: A qualitative Interpretive Description study was conducted across four hospitals in a regional health cluster in northern Saudi Arabia. Twenty‐three purposively sampled critical care nurses with direct experience of a unified electronic health record–integrated AI‐EWS participated in virtual semi‐structured interviews. Data were analysed using Braun and Clarke's reflexive thematic analysis, and reporting followed the COREQ 32‐item checklist. Findings: Four interpretive themes were identified: reading the algorithm through a nursing lens; the architecture of trust and override; responsibility, risk and the weight of disagreement; and autonomy reshaped at the human–algorithm interface. Nurses viewed algorithmic outputs as useful but insufficient, requiring interpretation through bedside assessment and contextual clinical knowledge. Trust was actively calibrated through experience, while override was framed as an accountable exercise of professional judgement. A subset of participants described overriding alerts without formal documentation under workload pressure, highlighting a governance gap at the human–algorithm interface. Disagreement with the algorithm was experienced as professionally exposing yet shaped by relational and organisational conditions, and sustained AI engagement reshaped surveillance practice, clinical authority and professional identity. Conclusions: AI‐EWS reorganise rather than replace nursing judgement. Safe integration depends not only on algorithmic performance but also on governance, training and interprofessional cultures that recognise and protect nurses' interpretive role at the bedside. Relevance to Clinical Practice: Critical care services should establish non‐punitive, low‐burden pathways for documenting overrides, provide training on trust calibration and discordant alerts, and position nursing leadership centrally in AI governance, implementation and evaluation.

Aim: To explore how neonatal nurses in Level III (high‐acuity) neonatal intensive care units recognise, interpret, and escalate early signs of clinical deterioration. Design: A qualitative interpretive description study underpinned by critical realism. Methods: Twenty‐two registered nurses were purposively recruited from four Level III units in the Jouf Region of northern Saudi Arabia using criterion‐based maximum‐variation sampling. Semi‐structured interviews were conducted in Arabic or English and analysed in their original language. Situation awareness and invisible work scholarship served as sensitising lenses. Rigour was supported through member reflection, negative‐case analysis, peer debriefing and an audit trail. Results: Four interrelated themes were identified: (1) ‘the infant tells you before the monitor does’, reflecting recognition of subtle deviation from the infant's baseline; (2) ‘building the case’, in which nurses tested and assembled evidence to make concern clinically credible before escalation; (3) ‘the escalation calculus’, describing how anticipated physician responses, hierarchy and previous dismissal shaped escalation and (4) ‘the unit works against you’, showing how alarm burden, documentation demands and staffing variability constrained vigilance. Recognition and escalation formed a cyclical, organisationally situated process rather than a single response to abnormal observations. Conclusion: Escalation involved interpretive, relational and legitimising work before early concern became actionable. Participants' accounts suggest that timely response depends on clinical expertise and environments that protect bedside attention and legitimise early escalation. Implications for the Profession and/or Patient Care: Neonatal services should protect surveillance capacity through staffing and workload design, alarm reduction, simulation of ambiguous deterioration and constructive escalation feedback. Impact: The study identifies case‐building as a distinct stage between noticing deterioration and escalating concern and indicates how organisational conditions may constrain early nursing surveillance. Reporting Method: Consolidated Criteria for Reporting Qualitative Research. No Patient or Public Contribution: Patients and the public were not involved.

Background: Shared 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. Aim: To 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 design: A 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 context: Twelve 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 considerations: Ethical 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. Findings: Four 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. Conclusions: Neonatal 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.