Experiences of PICU Nurses in Caring for Critically Ill and Dying Children: A Multinational Qualitative Study and Policy Implications

Abstract Background: Pediatric intensive care units (PICUs) represent some of the most emotionally and ethically challenging environments in nursing. Nurses caring for critically ill or dying children often report compassion fatigue, burnout, and moral distress, with downstream impacts on workforce sustainability and quality of care^1–3. While several studies have examined these experiences in single-country contexts such as the United States, China, and Iran^4–6, there remains limited cross-cultural evidence comparing stressors and coping mechanisms across multiple regions. Methods: We conducted a descriptive qualitative study involving 100 PICU nurses across ten countries (Saudi Arabia, Israel, United Kingdom, United States, Philippines, India, New Zealand, one African country, Russia, and Iraq/Iran). Stratified purposive sampling recruited 10 nurses per region with ≥1 year of PICU experience. Data were collected via semi-structured interviews conducted between January and June 2025, transcribed verbatim, and thematically analyzed using NVivo 12. Ethical approval was obtained from participating hospitals’ review boards, and informed consent was secured. Results: Three overarching themes emerged: (1) Stressors—nurses experienced profound sadness, helplessness, and fear of communication with families, compounded by staff shortages and high acuity workloads; (2) Consequences—compassion fatigue, burnout, and spillover of distress into personal life were common, though some reported strengthened faith and family values; and (3) Coping Strategies—self-regulation, peer solidarity, leadership reassurance, and reliance on spirituality (particularly in Middle Eastern and Filipino contexts) were identified. Variations across countries highlighted cultural influences: team-based debriefings in the UK/US versus faith-based resilience in the Philippines, Saudi Arabia, and India. Conclusions / Policy Implications: This multinational study underscores both shared and context-specific burdens of PICU nursing. Policies must prioritize adequate staffing, structured psychosocial support, and culturally sensitive end-of-life communication training. A SMART-framed roadmap is proposed, recommending that by 2027, ≥80% of tertiary hospitals in participating regions implement formal PICU debriefing protocols and faith-sensitive psychosocial services.