Abstract

Background Neonatal nursing care requires ethical competence alongside technical expertise. Despite progress in Spain, disparities persist in ethical training and professional autonomy in neonatal units. Objective To examine the ethical dimension of neonatal nursing in Spain, including training, institutional resources, ethical climate, and experiences of ethical conflict and moral distress. Research design A descriptive, observational, and cross-sectional study was conducted, combining quantitative and qualitative analyses to examine the ethical-professional reality of neonatal nurses nationwide. The study was based on an ad hoc questionnaire specifically designed for this research and validated through expert review and content validation procedures. Participants and research context A total of 307 neonatal nurses in Spain completed an online questionnaire developed by the researcher with 24 structured and semi-structured items. The sample size was determined based on voluntary nationwide participation during the 6-month data collection period, aiming to maximize territorial representation and professional heterogeneity among neonatal nursing staff. The instrument explored sociodemographic, educational, professional, and institutional variables, together with experiences of moral distress and ethical conflict. Ethical consideration The study followed the Declaration of Helsinki and Spanish and European data protection regulations. The questionnaire was fully anonymous, and no personal data or IP addresses were collected. Informed consent was obtained from all participants. As the study involved anonymous voluntary participation without clinical intervention or sensitive data processing, Ethics Committee approval was not required under regulations. Findings Most participants had non-formal bioethics training, whereas formal postgraduate education was rare. Moral distress was reported by 85% of respondents, mainly related to treatment limitation, therapeutic obstinacy, and end-of-life care. Bioethics training and professional experience predicted moral distress, while Clinical Ethics Committees showed no predictive value. These findings highlight the need to strengthen ethics education and promote participatory institutional environments to support ethical decision-making and reduce moral distress in neonatal nursing practice. Conclusion The ethical dimension of neonatal nursing in Spain is shaped by education, experience, and institutional climate. Training was associated with moral distress, but its impact depends on organizational support, underscoring the need for participatory environments to reduce suffering and strengthen ethical care.