Abstract
Background
Intensive care nurses may need to take proportionate first action before a revised medical order is available. In such moments, patient advocacy, role boundaries, and accountability intersect with fear of blame, uncertainty, and emotional burden, linking safe initiative to both patient safety and nurse well-being.
Aim
To explore how intensive care nurses in Turkey describe initiative in the absence of explicit orders, how they distinguish bounded professional courage from hesitation and recklessness, and what these experiences imply for supportive work environments.
Study Design
A qualitative descriptive study was conducted using a structured qualitative written instrument with open-ended items and a ranking task completed by 23 nurses from medical, surgical, anaesthesia, coronary, and neonatal intensive care units. Data were analysed using reflexive thematic analysis.
Results
Five themes were developed: recognising deterioration through converging cues; bounded professional courage as proportionate first action; hesitation as socially organised self-protection; recklessness as action without calibration, communication, or limit-awareness; and safe initiative as an organisational achievement. Hesitation was linked not only to inexperience but also to fear of harm, blame, rigid hierarchy, and ambiguous protocols.
Conclusions
Safe initiative in intensive care is best understood as bounded professional courage supported by organisational conditions. Clear protocols, accessible senior support, mentoring, simulation, and non-punitive climates can make timely action more possible while reducing the moral burden carried by nurses.
Relevance to Clinical Practice
Critical care leaders should clarify low-risk first actions, strengthen escalation pathways, and reduce punitive responses so that nurses can act promptly, safely, and with less fear-related strain.
Introduction
Intensive care nursing is practised in environments where physiological deterioration can unfold within minutes and where waiting for a revised order may expose patients to avoidable harm.1–4 The recognition of meaningful clinical change in this context – deterioration in saturation, haemodynamic status, consciousness, or behavioural pattern – often precedes the formal revision of medical orders, placing nurses in a position of ethically significant anticipatory responsibility. In such moments, nurses occupy an ethically and emotionally charged position: they are close enough to notice clinically meaningful change early, yet they remain accountable to professional boundaries, organisational expectations, and interprofessional hierarchy. The central question is therefore not merely whether nurses act, but what kind of action counts as justified when explicit direction is absent or delayed and how workplaces shape the burden of carrying that uncertainty.1–4
This article examines that question through the accounts of intensive care nurses in Turkey. It focuses on the middle ground between passive waiting and unsafe overreach and argues that safe initiative in intensive care is best understood as bounded professional courage: proportionate, competence-based, patient-oriented first action undertaken with escalation, communication, and accountability. This concept builds on existing scholarship on moral courage in nursing and situates it within the specific structural and relational constraints of intensive care practice.1–4
For the purposes of this study, several key concepts are defined as follows. Initiative without explicit orders refers to proportionate clinical action – such as repositioning, suctioning, adjusting oxygen support within training limits, tightening monitoring, or activating escalation pathways – taken by nurses before a revised medical order is obtained, in response to recognised deterioration. Bounded professional courage is defined as morally justified, competence-based first action that remains within the nurse’s training, maintains communication with the clinical team, and is oriented towards patient safety and timely escalation rather than autonomous clinical authority. Hesitation refers to deliberate deferral or self-protective delay despite recognition of meaningful clinical change, arising not only from uncertainty but also from relational, hierarchical, and institutional factors. Recklessness is defined as action without adequate clinical assessment, beyond one’s training or professional authority, bypassing communication, or detached from calibration. Passivity refers to the choice not to act despite recognition of clinical need, whereas overreach denotes action that exceeds legitimate professional boundaries and role expectations.
It is important to note that this study does not frame bounded professional courage as an expectation of individual heroism or as the normativisation of risk-taking behaviour. Rather, the concept describes the ethical middle ground that many intensive care nurses already occupy in practice – and aims to identify the organisational conditions that make that middle ground more or less accessible.
The relationship between nursing initiative, professional boundaries, institutional protocols, and physician communication is integral to this understanding. Nursing initiative in this context does not imply independent clinical authority or the assumption of physician-delegated responsibilities. It describes nurses’ exercise of professional judgement within their defined scope of practice in the interval before a revised medical order is obtained or a physician arrives. Institutional protocols delineate which first actions are permissible and expected in such intervals, while physician communication remains an essential concurrent responsibility rather than a precondition for all first steps.
Background/justification for the study
The language of moral courage has been used to describe nursing action taken for what is right despite risk, discomfort, or vulnerability.1–4 Across concept analyses and empirical work, courage in nursing is not equated with fearlessness. Rather, it is linked to advocacy, responsibility, integrity, and action in ethically difficult situations.1–4 Recent work in Nursing Ethics has further shown that morally courageous action is justified not only individually, but also contextually and organisationally. 4 These ethically loaded moments also matter for nurse well-being because repeated exposure to uncertainty, blame sensitivity, and morally consequential decisions can intensify stress and moral strain. The exercise of moral courage is grounded in nurses’ moral agency – the capacity to recognise morally significant situations, deliberate on appropriate action, and act in accordance with professional and ethical values despite contextual constraints.5,6 This moral agency operates in concert with nursing autonomy and clinical judgement, which together enable nurses to interpret deterioration, weigh competing considerations, and decide how to act safely within role boundaries.7,8 Ethical decision-making frameworks applied to intensive care nursing similarly emphasise that such decisions are shaped by teamwork, communication, and institutional ethics. 9
Evidence from Turkish and international nursing studies suggests that courage is shaped by working conditions rather than by character alone. Among emergency nurses in Turkey, courage has been linked to interactional justice and emotional exhaustion, 10 while ICU-based Turkish research during the COVID-19 period associated moral sensitivity and moral courage with how nurses navigated ethically difficult circumstances. 11 In parallel, related critical care symptom-management research suggests that ICU nurses often interpret converging bodily signs rather than isolated measurements, a point that matters for how ethically significant deterioration is recognised in practice. 12 Together, these studies indicate that organisational conditions shape not only safe action, but also resilience, fatigue, and the broader moral well-being of nurses.
Despite this growing literature, there is still limited empirical work on how nurses themselves draw the line between justified first action, hesitant delay, and reckless overreach in everyday high-acuity care. That gap is especially relevant for intensive care, where nurses are frequently expected to notice deterioration before others do, but where role boundaries remain salient. It also matters for contemporary discussions of nurse well-being because environments that leave nurses uncertain, unsupported, or vulnerable to blame may amplify stress while narrowing the space for timely action.
Aims and objectives/research questions/hypotheses
The study aimed to clarify the ethical meaning of safe initiative across different intensive care settings in Turkey and to identify the organisational conditions that make justified and timely first action more, or less, possible for nurses and their well-being.
The study addressed three research questions: (1) How do intensive care nurses describe initiative when explicit medical orders are absent, delayed, or no longer adequate to the patient’s immediate condition? (2) How do they distinguish bounded professional courage from hesitation and recklessness? (3) What organisational conditions support or inhibit safe initiative in critical care work environments? Because the study was qualitative and descriptive, no hypotheses were tested.
Design and methods
A qualitative descriptive design was adopted because the study sought close-to-practice accounts of ethically difficult action rather than formal theory generation. 13 Qualitative description was appropriate for preserving the language nurses used to explain what they saw, what they did, why they hesitated, and how they recognised the boundary between courage and overreach. The design was intentionally pragmatic and practice-near. Qualitative description was preferred over interpretive description because the study aimed to document the range of nurses’ experiences across multiple clinical settings rather than generate a thick interpretive account from a single population. Phenomenology was not selected because the goal was to explore professional reasoning and organisational conditions across diverse intensive care contexts, not to describe the lived experience of a bounded phenomenon.
Data were generated through a structured qualitative written instrument prepared in Turkish. A written qualitative format was selected for three reasons. First, the topic involved professionally sensitive situations in which participants might feel more comfortable reflecting privately than in a recorded interview. Second, the written format enabled participation across multiple intensive care settings and work schedules. Third, the form made it possible to capture both normative definitions and concrete case narratives in a standardised way without forcing all participants into the same spoken interactional style.
The instrument was developed iteratively. An initial draft was reviewed by two experienced intensive care nurses who were not participants in the study; their feedback was used to clarify terminology, adjust item sequencing, and ensure that the case narrative section elicited sufficiently detailed clinical and ethical reflection. The final form comprised the five linked components described in the table below.
Setting and sample
A purposive sampling strategy was employed to ensure representation across distinct intensive care contexts: medical, surgical, anaesthesia, coronary, and neonatal units in Turkey. Participants were recruited through unit managers in the participating institutions. Unit managers distributed study information to eligible nurses – those with at least 1 year of intensive care experience and currently practising in one of the target unit types. Participation was fully voluntary and anonymous; no incentives were offered. A precise response rate could not be calculated because forms were distributed by unit managers rather than directly by the research team; however, all returned forms were complete and were included in the analysis.
Twenty-three completed forms were included in the analysis. Participants worked in medical, surgical, anaesthesia, coronary, and neonatal intensive care settings in Turkey. The sample included both bedside and charge nurses and covered early-career, mid-career, and highly experienced clinicians. This heterogeneity was analytically important because it allowed comparison of how safe initiative was understood under different clinical risks and different distributions of authority.
Participant characteristics.
Mean age = 35.2 years (range 26–47); mean total nursing experience = 10.7 years (range 2–24); mean intensive care experience = 6.8 years (range 1–18).
Structure and analytic contribution of the structured qualitative written instrument.
Note. The categories of hesitation, courage, and recklessness represent theoretically informed prompts used to elicit participants’ own interpretations in data collection, not predetermined analytic findings; the thematic analysis examined how participants understood and complicated these distinctions.
Data collection tools and methods
The form contained five linked components: demographic and professional items; a ranking task on situations in which nurses most often felt pressure to take initiative without clear orders; open-ended questions on the meaning of such initiative; prompts that explicitly asked participants to differentiate hesitation, courage, and recklessness; and a structured case narrative section asking for one memorable or instructive event. The case section prompted respondents to describe clinical signs, actions taken, risks considered, communication processes, perceived outcomes, and reflections on whether they would act similarly again. This structure produced data that were both conceptual and situational.
Data analysis
Analysis followed reflexive thematic analysis.14,15 The dataset was analysed in the source language, Turkish, to preserve nuance in terms such as cekingenlik (hesitancy/withdrawal), cesaret (courage), and gozu kara/pervasiz (rashness/recklessness). The first analytic movement involved repeated reading of all forms and drafting concise case summaries. The second involved open coding focused on triggers for action, meanings attached to initiative, descriptions of hesitation, descriptions of recklessness, and references to organisational conditions. The third involved grouping related codes into candidate themes and comparing them across unit types and experience levels. The fourth involved theme refinement through sustained comparison with original form material, including tension-bearing and contradictory cases. Initial coding was conducted by the first author. Open coding was then carried out independently by two members of the research team; any discrepancies were resolved through sustained comparative discussion rather than through statistical inter-rater agreement, consistent with reflexive thematic analysis. 15 The analytic process was both inductively grounded in the data and informed by the theoretically motivated prompts in the instrument; this balance is consistent with a qualitative descriptive design and is stated explicitly rather than implied.
Situations most frequently prioritised for initiative in the absence of explicit orders [Data derive from the structured ranking component of the instrument; reported as descriptive contextual background, not as an output of the reflexive thematic analysis].
aMean priority rank is calculated among forms in which the item was ranked (1 = highest priority).
The analysis deliberately attended to disconfirming and ambivalent material. Some less-experienced nurses described clear, bounded first action when protocols and support were strong, whereas some highly experienced nurses described marked hesitation in settings where consequences felt especially grave. These tensions were treated as analytically productive rather than as errors to be smoothed away. Consistent with reflexive thematic analysis, the study did not treat inter-rater reliability as the primary marker of quality. 15 Instead, rigour was supported through transparency of analytic steps, cross-case comparison, retention of an audit trail linking themes to source material, and explicit attention to alternative readings. 17
The achieved sample was variation-oriented rather than statistically representative. The study was designed to capture ethically relevant similarities and differences across intensive care contexts, not to estimate prevalence. The adequacy of the sample was judged with reference to information power: the study question was focused, the material was rich in concrete case-based reflection, and the analytic aim was conceptual clarification rather than population generalisation. 18 Reporting was guided by the Standards for Reporting Qualitative Research. 17
To preserve anonymised review while still addressing reflexivity, the author team is described at a generic level in the manuscript. The team combined expertise from nursing and organisational scholarship. This combination shaped the analysis in a useful way: accounts were read not only as descriptions of bedside clinical judgement, but also as situated expressions of hierarchy, responsibility, role interpretation, and institutional climate. Reflexive discussion within the team was used to challenge overly individualised readings of courage and hesitation. In terms of disciplinary background: team members brought clinical experience in intensive care nursing, expertise in nursing ethics and qualitative methodology, and background in organisational analysis and institutional behaviour. The clinical members contributed recognition of practice nuance; the ethics and organisational scholars contributed conceptual frameworks for interpreting hesitation and courage at the institutional level. This disciplinary combination shaped decisions about which analytic readings to accept, challenge, or qualify at each stage of theme development.
Ethical considerations
The study involved written reflections on ethically sensitive practice situations and therefore required careful attention to voluntariness, confidentiality, and professional risk. Ethical approval was granted by an institutional research ethics committee in Turkey on 11 July 2024 (application no. E.183271; meeting no. 6; decision no. 2; approval document no. 17.07.2024-24440). Written informed consent was obtained prior to participation. No participant names, institutions, or ward-level identifiers were retained in the manuscript. The qualitative forms nevertheless contained potentially identifying professional detail, so quotations were lightly edited for English reporting where necessary without altering substantive meaning. Participant identifiers, such as P01 and P11, are used only to indicate analytic provenance.
Trial registration (if applicable)
Not applicable. This was a qualitative descriptive study and did not involve a clinical trial.
Results/findings
Final themes, subthemes, and analytic meanings.
Distinguishing hesitation, bounded professional courage, and recklessness.
Cross-context patterns in bounded professional courage [Developed using framework matrix principles 16 after thematic development was complete; represents cross-context variation display, not a separate analytic method].
Recognising deterioration through converging cues
Participants rarely described initiative as being triggered by one isolated alarm value. What moved them towards action was usually a converging picture: falling saturation together with rising ventilator pressures and visible breathing difficulty; hypotension together with oliguria, drainage change, pallor, or altered behaviour; or a patient’s overall presentation shifting away from the expected course. Sudden desaturation or respiratory distress and haemodynamic deterioration were each prioritised by 22 of the 23 nurses, followed closely by significant worsening in monitor or alarm findings.
A senior surgical participant explained that numbers were important but not sufficient: sometimes, before the monitor values worsen dramatically, ‘the patient’s colour, sweating, agitation or unusual silence already signals that something is wrong’ (P01, surgical ICU). A coronary nurse similarly described being activated when a patient departed from the expected rhythm and behavioural pattern rather than when one threshold alone was crossed (P16, coronary ICU).
This pattern-based noticing matters ethically because it positioned the nurse as an interpreter of change rather than a passive recorder of values. The moral difficulty of initiative began at the moment when a cluster of cues was understood as meaningful but the next legitimate step remained uncertain. In other words, the ethical problem did not start with action; it started with recognition.
Bounded professional courage as proportionate first action
Across units, courage was described less as boldness than as proportionate first action for the patient’s good. Participants associated courage with repositioning, checking airway patency, suctioning when trained and indicated, adjusting oxygen support within accepted limits, verifying vascular access, tightening observation, recalculating intake-output, preparing equipment, activating senior support, and informing physicians without delay. These actions were consistently framed as time-buying, patient-protective, and explainable rather than heroic or independent.
A charge nurse in medical intensive care defined courage as evaluating the patient, initiating safe measures within training boundaries, and informing the physician at the same time (P07, medical ICU). A less-experienced surgical nurse described courage not as ‘doing everything alone’ but as taking the right first step, reducing environmental stress, reassessing vital signs, and asking for senior support while keeping the patient safe (P02, surgical ICU).
Participants therefore linked courage to three intertwined features: clinical justification, competence limits, and ongoing communication. Action became ethically defensible not because it was fast, but because it was proportionate, bounded, and accountable. This understanding was visible in the case narratives, where even highly proactive respondents emphasised that they had not changed medication orders or crossed professional limits.
Hesitation as socially organised self-protection
Hesitation was often described as repeated checking, waiting, deferring, and searching for confirmation despite recognition that the patient might be worsening. Participants linked this not only to inexperience but also to fear of harming the patient, fear of blame afterwards, previous critical feedback, uncertain protocols, and strained relationships with physicians or senior staff. Waiting was therefore narrated as a socially organised form of self-protection, as much as an individual emotional reaction, and as a source of ongoing moral strain.
One medical ICU nurse wrote that she would monitor more closely and seek confirmation because she was afraid that a wrong step could harm the patient and leave her responsible for the outcome (P11, medical ICU). An experienced coronary nurse similarly described knowing what likely needed to be done, but holding back because earlier interactions with certain physicians made any initiative feel vulnerable to criticism or misinterpretation (P16, coronary ICU).
The neonatal narratives made this especially vivid. Even experienced neonatal nurses described how the extreme fragility of infants intensified responsibility and made active intervention feel dangerous unless protocols were explicit or senior approval was immediate. In this sense, hesitation was not simply the absence of courage. It was often the emotional expression of a workplace in which the burden of consequences felt asymmetrical and poorly shared.
A cross-cutting pattern concerned experience. Novice nurses certainly described uncertainty, reliance on protocols, and the need for reassurance. Yet, some highly experienced nurses also described strong inhibition, especially in neonatal and coronary settings where the perceived cost of error was exceptionally high. Experience did not linearly produce fearlessness; in some contexts it sharpened anticipatory awareness of harm and thereby intensified caution.
Recklessness as loss of calibration
Participants were equally clear that not every rapid intervention is courageous. Recklessness was described as acting without adequate assessment, bypassing communication, or stepping beyond one’s training or authority. Examples included changing medication doses without an order, giving aggressive fluid treatment without understanding the cause of hypotension, or forcing procedures before clarifying why deterioration was occurring.
As one participant put it, ‘the difference between courage and recklessness is clinical justification, safety boundaries and accountability’ (P01, surgical ICU). Another reflected that sometimes experience can create false certainty and encourage responses that are ‘more reflex than judgement’ (P16, coronary ICU).
This theme is analytically important because it shows that participants did not equate passivity with caution and action with virtue. Instead, they drew an ethical distinction within action itself. Courage was morally bounded action; recklessness was action detached from calibration.
Safe initiative as an organisational achievement
Participants repeatedly located safe initiative, and the emotional sustainability of this work, in the wider organisation of practice. Clear protocols, mentoring, approachable physicians, senior-nurse backing, team trust, opportunities for simulation, constructive feedback, and a non-punitive climate were described as the main enablers of courage. Under these conditions, nurses said they could recognise change earlier, present observations more clearly, and undertake low-risk supportive measures with less paralysis and less fear-related strain.
One participant summarised this point directly: safe courage is strengthened less by individual bravery than by a system that supports the nurse (P01, surgical ICU). The same logic recurred in different words across the dataset. Where communication was open and role expectations were clear, participants described initiative as more timely and more measured. Where hierarchy was rigid or feedback punitive, even knowledgeable nurses became quieter, slower, and more deferential.
The case narratives showed that supportive systems did not encourage recklessness. On the contrary, participants felt most able to act safely when supervision, protocols, and escalation channels were clear. Organisational support widened the ethical space for bounded initiative rather than removing limits from practice.
Discussion
This study contributes to critical care nursing by theorising safe intensive care initiative as bounded professional courage. Participants did not frame ethically sound action as either passive obedience or independent clinical authority. Instead, they described a middle space in which the nurse recognises meaningful deterioration, undertakes proportionate and competence-based first measures, and escalates while remaining communicatively and professionally accountable. This extends prior moral courage scholarship by showing that the relevant contrast in acute care is not simply courage versus fear, but calibrated action versus both avoidable delay and overreach.1–4,19 The interpretation is also consistent with scholarship that treats courage as a practical and risk-bearing element of care rather than as individual heroism alone.20,21
The concept of calibrated action as used in this study refers specifically to clinical action that is proportionate to the recognised clinical picture, consistent with the nurse’s training and authority, and accompanied by simultaneous communication and escalation. In intensive care practice, this might involve a nurse who observes progressive oxygen desaturation in a ventilated patient: calibrated action would include repositioning, checking circuit integrity and suction need, increasing observation frequency, and calling the responsible physician – all within the nurse’s scope – rather than independently adjusting ventilator settings or postponing action until saturation has deteriorated further. The ethical significance of calibration lies in its orientation: it holds action within what is professionally defensible while still serving the patient’s immediate needs.
Situated moral agency similarly requires grounding in clinical context. Participants’ accounts showed that moral agency in intensive care is not a stable capacity exercised identically across situations. Rather, it is co-produced by the specific features of the encounter: the patient’s fragility, the clarity of institutional protocols, the accessibility of senior support, and the relational quality of the team. An experienced neonatal nurse, for instance, may exercise strong clinical judgement but constrain her moral agency when protocols are ambiguous and senior approval is not immediately available – not from lack of courage, but from a situated assessment of risk. This understanding is grounded directly in the participants’ accounts and is consistent with philosophical accounts of situated practical wisdom.
A second contribution concerns the critical care work environment and nurse well-being. The data show that hesitation is frequently produced by workplace arrangements rather than by individual weakness alone. Fear of blame, inaccessible physicians, punitive feedback, and ambiguous boundaries narrowed the space for action, whereas protocol clarity, respectful communication, mentoring, and simulation widened it. This pattern resonates with prior work showing that courage in nursing is shaped by interactional justice, unit climate, and the broader moral ecology of practice.4,10,11,22,23 The theme of hesitation as socially organised self-protection deserves particular elaboration. The accounts collected in this study reveal that hesitation is not simply individual anxiety or inexperience; it is a response shaped by relational history with colleagues, the perceived fairness of feedback processes, and the visibility of punitive consequences for previous initiatives. Nurses described hesitation as a form of institutional memory – a learned behavioural response calibrated to specific workplace dynamics rather than to the clinical situation alone. This framing locates the source of delay not in the individual nurse’s courage deficit but in the social and institutional arrangements that make action feel asymmetrically risky, and suggests that interventions aimed solely at building individual confidence will be insufficient if those conditions remain unchanged.
The organisational reading of hesitation is further supported by the wider critical care literature on moral distress, burnout, and resilience. ICU studies and reviews show that moral distress is associated with professional role, workplace distress, organisational justice, and ICU-specific stressors, while burnout and psychological strain remain recurrent problems among critical care nurses and healthcare professionals.24–31 These findings support the argument that safe initiative cannot be reduced to individual confidence; it is shaped by whether nurses experience the unit as fair, supportive, and non-punitive.
The findings also connect to patient-safety research on interdisciplinary communication and speaking up. Studies of ICU communication, teamwork, medical mishaps, psychological safety, and safety-related voice show that clinicians may withhold concerns even when they recognise potential harm, especially where hierarchy, role ambiguity, weak team climate, or fear of negative consequences are present.32–39 This literature strengthens the practical interpretation of the present findings: escalation pathways, shared mental models, and psychologically safe communication are not optional additions to courage; they are conditions that help keep initiative bounded and safe.
The cross-context differences identified across ICU settings merit further reflection. Medical ICU nurses described hesitation arising from the complexity of multi-system deterioration and the difficulty of identifying a single initiating action that would be clearly defensible. Neonatal nurses described a distinctive intensification of hesitation arising from the perceived extreme fragility of their patients and the moral weight attached to even small interventions. Coronary nurses described hesitation related to the speed and unpredictability of rhythm changes and relational dynamics with cardiologists. Surgical and anaesthesia nurses described hesitation arising from post-operative ambiguity about expected versus unexpected change. These differences suggest that training for bounded professional courage cannot be generic: simulation, mentoring, and protocol development must be calibrated to the specific clinical and relational features of each intensive care environment.
A further consideration concerns the relationship between organisational support for safe initiative and the maintenance of clear professional role boundaries. Participants’ accounts consistently showed that supportive conditions – protocol clarity, accessible supervision, non-punitive feedback – did not blur boundaries or encourage overreach. On the contrary, nurses in the most supported environments described the most precise and well-bounded initiative: they acted earlier, more deliberately, and more within their scope precisely because they understood both what was expected and what was permissible. Organisational support strengthens professional courage by making role boundaries clearer, not by dissolving them.
The findings also sharpen the conceptual distinction between courage and recklessness. Participants did not treat recklessness as greater bravery; they treated it as action without assessment, communication, or limit-awareness. That distinction matters in intensive care because moral language can otherwise romanticise decisive action and obscure the ethical importance of calibration. The participants’ accounts instead suggest that safe initiative is ethical precisely when it remains explainable, competence-based, and open to team scrutiny.
The study further complicates any assumption that more experience automatically means greater readiness to act. Experience sometimes enabled earlier recognition and more confident first measures, but in highly fragile settings it could also intensify caution by deepening awareness of potential harm. In this respect, courage is not a stable personality trait carried unchanged across settings. It is better understood as situated professional agency whose practical form is co-produced by patient fragility, role clarity, and organisational support.
Limitations
Data were generated through written forms rather than interviews or observation. This design produced breadth across contexts and reduced interviewer influence, but it limited opportunities to probe ambiguity in real time. Importantly, the absence of face-to-face or recorded interviews means that the emotional nuances of nurses’ experiences – the embodied expression of hesitation, the relational dynamics of difficult moments, or the interactional texture of decision-making under pressure – were necessarily mediated through written accounts and may be less fully accessible than in interview-based studies. The dataset was also self-reported and retrospective, meaning participants may have reconstructed events through later reflection or social desirability. In addition, the sample was analytically diverse rather than statistically representative. The goal was conceptual and ethical clarification, not generalisation to all intensive care nurses in Turkey. The deliberate cross-context heterogeneity of the sample – spanning five ICU types with different patient populations, clinical risks, and relational dynamics – was analytically productive but also introduces interpretive complexity. Patterns appearing consistent across settings may conceal important unit-specific variation that a single-context study with larger sample size might reveal. Future research would benefit from in-depth single-context studies that can examine these dynamics in finer detail. Analysis in Turkish protected nuance, but translation for reporting may still have softened some linguistic distinctions.
Recommendations or implications for practice and/or further research
These findings have direct implications for practice, leadership, education, and workforce well-being in critical care. Unit protocols should specify which low-risk supportive measures are expected while escalation is underway. Debriefing and simulation should address not only technical tasks but also the ethical logic of when to step forward, when to escalate, and where the boundary of safe initiative lies. Related studies in emergency nursing, disaster nursing, and nurses’ experiences following the Kahramanmaraş earthquake similarly indicate that courage is relational, context-sensitive, and shaped by environments that do not punish justified action.10,40,41 Recent calls for more standardised disaster content in nursing education also reinforce the need for structured preparation for ethically demanding action, not only technical instruction. 42
Further research could examine how nurses, physicians, and managers interpret the same moments of delayed order, role uncertainty, and early deterioration. Observational, interview-based, and comparative studies across intensive care settings could also clarify how protocol clarity, escalation routines, and feedback culture shape both patient safety and the psychological cost of acting under uncertainty.
Conclusion
The practical challenge is not to celebrate daring action in the abstract, but to create intensive care environments in which justified and timely first action is more possible and less psychologically costly for nurses. When protocols are clear, senior support is accessible, and the climate is not punitive, nurses are better able to occupy the middle ground between paralysis and recklessness while sustaining their professional well-being.
• Intensive care nurses often recognise deterioration before a revised medical order is available. • Moral courage in nursing involves acting for the patient despite fear, vulnerability, and professional risk. • Ambiguous role boundaries, hierarchy, and blame-sensitive climates can burden nurses and delay safe escalation.
• This study conceptualises safe intensive care initiative as bounded professional courage rather than heroic independence. • It distinguishes hesitation, bounded professional courage, and recklessness through nurses’ own accounts of high-acuity practice. • It identifies protocol clarity, accessible senior support, mentoring, simulation, and non-punitive feedback as conditions that make initiative safer and less psychologically costly.Impact statement
What is known about this topic
What this paper adds
Footnotes
Author contributions
All authors contributed to the conception or design of the study, interpretation of the data, critical revision of the manuscript, and approval of the final submitted version. The corresponding author coordinated manuscript preparation and submission.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The qualitative data are not publicly available because they contain potentially identifying professional detail and were collected under confidentiality assurances.