Navigating the Implementation of Pediatric Palliative Care: Nurses’ Perspectives and the Emerging Role of the Advanced Practice Nurse

Navigating the Implementation of Pediatric Palliative Care: Nurses’ Perspectives and the Emerging Role of the Advanced Practice Nurse | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating the Implementation of Pediatric Palliative Care: Nurses’ Perspectives and the Emerging Role of the Advanced Practice Nurse Simone Saringer-Siegl¹²³, Roland Eßl-Maurer¹, Piret Paal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7102048/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Feb, 2026 Read the published version in European Journal of Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: This study explores nurses’ attitudes and support needs during the implementation of a pediatric palliative care (PPC) concept at a tertiary children’s hospital in Austria. Methods: A qualitative, participatory research design was employed. Four moderated focus groups involving 18 nurses from two PPC-integrated wards were conducted. Data were transcribed verbatim and analyzed using Braun and Clarke’s Thematic Analysis. Results: Analysis revealed four themes: (1) experiences with PPC, (2) PPC as a new model of care, (3) challenges of implementation, and (4) expectations toward PPC. While nurses viewed PPC as a valuable, family-centered concept, they reported emotional strain, time constraints, and communication barriers. The term “palliative” was frequently associated with death, highlighting the need for cultural reframing and education. Conclusions: Successful PPC implementation requires emotional readiness, interprofessional collaboration, and dedicated support structures. Nurses expressed a strong desire for structured guidance, training, and the presence of an Advanced Practice Nurse (APN) to provide clinical and emotional support. pediatric palliative care nursing attitudes participatory research implementation support needs What is known / What is new What is known - Pediatric palliative care is often misunderstood as synonymous with end-of-life care. - Implementing PPC in pediatric hospitals requires complex organizational change. What is new - Nurses value PPC as a family-centered model but need emotional and professional support. - An Advanced Practice Nurse can serve as a facilitator during PPC implementation. - Participatory approaches effectively identify frontline challenges and attitudes in PPC settings. Introduction Despite low childhood mortality rates in high-income countries, the prevalence of life-limiting conditions is increasing (1,2). This trend presents significant emotional, organizational, and professional challenges for healthcare providers. Pediatric palliative care (PPC) is a holistic, multidisciplinary approach designed to improve quality of life for affected children and their families by addressing medical, psychological, social, and spiritual needs (3,4). It is not limited to end-of-life care but is initiated early in the course of illness and can be delivered alongside curative treatments. The implementation of PPC requires substantial cultural and organizational shifts within hospital settings and challenges traditional care models (5). As such, PPC necessitates not only structural but also professional transformation, including specialized roles and competencies within nursing (5). The conceptualization and successful integration of PPC is increasingly linked to the expertise of Advanced Practice Nurses (APNs) who possess additional qualifications in pediatric palliative care (4,5,6). These nurses play a critical role in bridging clinical practice, patient advocacy, interprofessional coordination, and ethical reflection. Their advanced training enables them to support complex decision-making processes, provide symptom management, and offer psychosocial guidance to families throughout the illness trajectory (6). Advanced Practice Nursing has emerged in recent decades as a response to the growing complexity of patient needs and healthcare systems. APNs are registered nurses with graduate-level education and expanded clinical competencies. Their roles include clinical experts, consultants, educators, and leaders in evidence-based practice (7). In pediatric palliative care, APNs contribute to quality improvement by initiating care models, mentoring staff, and ensuring family-centered, ethically grounded interventions (3,4,5,7). These developments align with international efforts to strengthen palliative care services through role differentiation and advanced clinical leadership (2,5,7). In 2022, the Children’s Center of the University Hospital Salzburg initiated the structured implementation of a PPC concept. As part of this initiative, a dedicated multiprofessional team was established to provide an additional layer of support for patients with life-limiting conditions and their families. This team ensures comprehensive, family-centered care and supports ward-based treatment teams in managing the complex demands of pediatric palliative care. However, little is known about the frontline experiences of nursing staff during such transformations. This study investigates nurses’ attitudes, emotional burdens, and support needs during the implementation of PPC. The findings aim to guide future role development of Advanced Practice Nurses (APNs) and to refine clinical strategies for integrating PPC into pediatric care. Materials and Methods Study Design A qualitative, participatory research design was employed to explore the experiences of nurses involved in PPC implementation. This approach enabled nurses to contribute to the research process and express their perspectives openly. Setting and Participants The study was conducted at the Children’s Center of the University Hospital Salzburg, a tertiary hospital in Austria. In 2022, the hospital began integrating dedicated PPC beds within two pediatric wards (a Neonatal and Infant Ward and a Parent-Child Ward). Purposive sampling was used to recruit registered nurses from both wards. Eligibility criteria included a minimum of six months of professional experience on the respective ward and direct involvement in caring for children with life-limiting conditions. A total of 18 nurses (17 femals, aged 24–55) participated. Data Collection Data were collected through four moderated focus group discussions, each comprising 4–5 participants in November 2022. Discussions were conducted in a private meeting room at the hospital and lasted 60–90 minutes. A semi-structured interview guide was developed based on existing literature and clinical insights (8,9). The guide covered the following areas: prior experiences with PPC, perceptions of the new care model, challenges encountered during implementation, and support needs. All discussions were audio-recorded and transcribed verbatim. Data Analysis Data were analyzed using Braun and Clarke’s six-phase Thematic Analysis (10). The first author performed initial coding and theme generation, supported by peer debriefing with the co-authors. Discrepancies were resolved through consensus discussions. The analysis process involved: (1) familiarization with the data; (2) generating initial codes; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; and (6) producing the final report. Ethical Considerations Ethical approval was obtained from the Ethics Committee of the Paracelsus Medical University (SS22-0046-0046). Written informed consent was secured from all participants. Results The analysis of the focus group data was conducted following Braun and Clarke’s six-phase approach to Thematic Analysis (3). This method provided a structured and transparent framework for analyzing the data and allowed for a systematic exploration of patterns across the dataset. Through the analysis prozess four main themes and 15 subthemes were identified (Table 1). These themes capture nurses’ experiences, perceptions, and expectations regarding the implementation of PPC. In the following sections, each theme is presented with illustrative participant quotes and interpretive commentary to convey both the content and the emotional nuances of the findings. Theme Subthemes 1. Experiences with PPC 1a) Longstanding presence of PPC practices 1b) Lack of training 1c) Avoiding the taboo of death 1d) Need for structured support and training 2. PPC as a New Model of Care 2a) Conceptual confusion 2b) 'Palliative' as a trigger for fear 2c) Recognition of PPC as life-long care 3. Challenges of Implementation 3a) Emotional burden 3b) Managing parental expertise and expectations 3c) Time limitations 4. Expectations Toward PPC 4a) Communication strategies 4b) Role and expectations of the PPC team 4c) Desired support through an APN Table 1. Overview of Themes and Subthemes Theme 1: Experiences with Pediatric Palliative Care Nurses shared longstanding experiences in caring for children with complex and life-limiting conditions. Despite the absence of a formal PPC framework in previous years, many participants had been involved in emotionally demanding caregiving situations. "I’ve been working with patients like this for a long time. At the beginning, I often thought they were completely alone, with no support at all." (Group II) 1a) Longstanding presence of PPC practices Several participants reported that aspects of PPC had long been part of their daily practice, even if not explicitly named as such. 1b) Lack of training Despite years of practical experience, nurses described a lack of formal education or conceptual understanding regarding PPC. 1c) Avoiding the taboo of death Discussing death openly remained difficult, both within teams and with families. This avoidance often led to uncertainty in communication. 1d) Need for structured support and training Participants highlighted the absence of structured training and reflection opportunities, especially when dealing with death and dying. Thematic summary: Although many nurses had long cared for severely ill children, the lack of formal training and structured support led to fragmented practices and emotional insecurity. The reluctance to openly address death further compounded this ambiguity. This theme reveals a latent PPC culture lacking systemic anchoring. Theme 2: PPC as a New Model of Care While PPC was generally viewed positively, it was perceived as an unfamiliar and emotionally charged concept. 2a) Conceptual confusion Participants expressed uncertainty regarding what constitutes PPC, and where their own responsibilities begin and end. 2b) 'Palliative' as a trigger for fear The term “palliative” was frequently associated with end-of-life and death, leading to resistance or unease among staff and even affected families. "Death was not permitted to occur on our ward either... patients would be transferred elsewhere beforehand." (Group IV) 2c) Recognition of PPC as life-long care Over time, many participants began to understand PPC as a long-term, family-centered support approach rather than solely terminal care. Thematic summary: This theme reflects the internal negotiation process within nursing teams as they reframe PPC from a "death-centered" to a "life-supporting" concept. Language, cultural attitudes, and institutional history played a central role in shaping nurses’ understanding and acceptance of PPC. Theme 3: Challenges of Implementation The introduction of PPC triggered emotional, communicative, and organizational tensions within daily practice. 3a) Emotional burden Participants described PPC implementation as emotionally exhausting, particularly due to feelings of helplessness and fear of doing harm. "I feel highly insecure and fear that I am providing suboptimal care. I try to avoid this type of care as much as possible." (Group IV) 3b) Managing parental expertise and expectations Families often arrived well-informed and emotionally involved, which created pressure on nurses to deliver expert and emotionally responsive care. 3c) Time limitations Participants reported that high workload and limited time per patient hampered their ability to fully engage in PPC, particularly in emotionally complex cases. Thematic summary: This theme highlights the emotional and structural barriers nurses face when implementing PPC in a fast-paced hospital environment. It underscores the necessity of institutional support systems to manage emotional stress and provide the resources required for sustainable PPC practices. Theme 4: Expectations Toward PPC Looking forward, nurses formulated clear expectations regarding how PPC should be supported and structured within the institution. 4a) Communication strategies Participants emphasized the importance of regular team communication and reflection opportunities. "Communication is key. Even five minutes during lunch to check in — does anyone have an issue? That would help." (Group I) 4b) Role and expectations of the PPC team Nurses expected PPC teams to be visible, approachable, and actively involved in care planning and team support. 4c) Desired support through an APN Many participants saw a designated APN as a key resource person who could bridge clinical practice, emotional support, and educational needs. Thematic summary: This theme articulates nurses’ need for structured communication, accessible expertise, and emotional support. The APN was envisioned as a central figure to coordinate and reinforce PPC within the clinical setting. Discussion This study illustrates the complexity of implementing pediatric palliative care (PPC) within a hospital setting. Although nurses acknowledged PPC’s value, the term “palliative” was frequently associated with death, which contributed to emotional discomfort and initial resistance — a phenomenon consistently reported in the literature (4,11). The participatory research design was instrumental in uncovering these frontline experiences and emotional barriers. Previous studies emphasize that involving nursing staff early in implementation processes fosters ownership and mitigates resistance (8,11). In this context, the involvement of an Advanced Practice Nurse (APN) emerged as a critical facilitator for easing the transition and supporting both clinical and emotional needs of nursing staff (12). International frameworks such as GO-PPaCS (5) and IMPaCCT (1) strongly advocate for early integration of PPC, role clarity, and interprofessional collaboration. Our findings are in line with these recommendations and highlight the urgent need for structured training, institutional emotional support, and dedicated communication strategies to ensure successful PPC implementation. Importantly, this study sheds light on the emotional responses of nurses — ranging from fear and uncertainty to empathy and dedication. Similar patterns have been described by Bergsträsser et al. (12), who noted that lack of preparation and reflection opportunities can result in emotional exhaustion and professional withdrawal. Without adequate institutional support, these risks may jeopardize both staff well-being and care quality (13). Embedding an APN into PPC implementation can mitigate these risks. As documented by Cormack et al. (8) and Cormack & Dahlin (11), APNs serve not only as clinical experts but also as mentors, role models, and agents of change. They facilitate interdisciplinary collaboration, provide tailored education, and foster psychological resilience among team members (8,11). The APN’s role in this context emerged as particularly valuable in linking theoretical concepts with everyday clinical practice. In this study, the APN functioned as a “bridge” between conceptual frameworks and clinical reality — a finding supported by international case studies in PPC role development (8,11). The APN contributed to integrating pediatric palliative care into existing care structures, while also promoting reflection, team support, and quality improvement efforts. Furthermore, the desire for a structured, clearly defined APN role expressed by participants resonates with recommendations for advanced nursing practice in PPC outlined by Schober & Affara (9), Streuli et al. (10), and Bergsträsser et al. (12). The APN can effectively counteract conceptual ambiguities, reduce emotional strain, and provide ongoing mentorship — all of which are crucial for sustaining PPC integration in pediatric hospital environments. Strengths and Limitations This study provides valuable insights into the experiences of nurses during the early phase of PPC implementation in a tertiary hospital setting. The participatory design enabled the identification of real-world challenges and emotional barriers. However, limitations include the single-center setting and the relatively small sample size, which may limit generalizability. Future research should explore longitudinal perspectives and involve multidisciplinary teams to further inform PPC integration strategies. Conclusion Implementing PPC requires more than organizational change; it demands emotional readiness, structured support, and interprofessional collaboration. Nurses play a pivotal role in delivering PPC but need clear guidance, ongoing education, and emotional reassurance. Embedding an Advanced Practice Nurse (APN) within PPC teams has the potential to significantly enhance implementation success. The APN can serve as a clinical expert, facilitator of interprofessional collaboration, and emotional support for nursing staff. As such, the structured integration of an APN should be considered a key component of sustainable PPC implementation strategies in pediatric healthcare settings. Abbreviations APN Advanced Practice Nurse ANP Advanced Nursing Practice PPC Pediatric Palliative Care WHO World Health Organization TA Thematic Analysis Declarations Ethical Approval This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the institutional ethics committee of the Paracelsus Medical University (SS22-0046-0046). Informed Consent Written informed consent was obtained from all individual participants. Conflict of Interest The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution S.S wrote the main manuscript text and all authors reviewed the manuscript. Data Availability The data is password-protected and stored in a neutral location. It is not possible for anyone to draw conclusions about a person based on the written group discussion. All anonymized data of the group discussions and their transcription as well as the declarations of consent are secured and stored by the researcher against unauthorized access. References Craig F, Abu-Saad Huijer H, Benini F, Kuttner L, Wood C, Feraris PC. IMPaCCT: standards for paediatric palliative care in Europe. Eur J Palliat Care. 2007;14:109–114. Benini F, Papadatou D, Bernadá M, et al. International standards for pediatric palliative care: The GO-PPaCS project. J Palliat Med. 2022;25:698–707. doi:10.1089/jpm.2021.0428 Braun V, Clarke V. Thematic Analysis: A Practical Guide. London: SAGE Publications; 2022. Zernikow B, Michel E, Garske D. Pädiatrische Palliativversorgung: Konzepte, Herausforderungen und Entwicklungen. Z Kinder Jugendpsychiatr Psychother. 2013;41:399–405. Streuli JC, von Mengershausen A. Ethical challenges in pediatric palliative care: A literature review. Palliat Med. 2021;35:457–465. Thaxton, C.A. & Neubauer, L. (2016). The Role of the Pediatric Palliative Advanced Practice Registered Nurse. In: C. Dahlin, P. Coyne & B. Ferrel (Hrsg.). Advanced Practice Palliative Nursing . (S. 545–551). New York: Oxford University Press. Tracy, MF. & Sendelbach, S. (2019). The Clinical Nurse Specialist. In M.F. Tracy & E.T. O’Grady (Hrsg.) Advanced Practice Nursing: An integrative approach. S. 343–373. St. Louis, Missouri: Elsevier Cormack M, Devaney C, Rainsford S. Role development of the Advanced Nurse Practitioner in paediatric palliative care: A review. Child Care Health Dev. 2022;48:163–172. Schober M, Affara F. Advanced Nursing Practice. Oxford: Blackwell Publishing; 2008. Streuli J, Bergsträsser E, Flury M, Satir A. Kinder-Palliativmedizin Essentials. Bern: Hogrefe Verlag; 2018. Cormack CL, Dahlin C. The Pediatric Palliative APRN: Leading the Future. J Pediatr Health Care. 2022;36:381–387. doi:10.1016/j.pedhc.2022.01.005 Bergsträsser E, Inglin S, Abbruzzese R, et al. The needs of professionals in the palliative care of children and adolescents. Eur J Pediatr. 2012;172:111–118. doi:10.1007/s00431-012-1880-8 Roland J, Lambert M, Shaw A, et al. The children’s palliative care provider of the future: A blueprint to spark, scale and share innovation. Imperial College London; 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Feb, 2026 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 12 Sep, 2025 Reviews received at journal 10 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviews received at journal 10 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Editor assigned by journal 17 Jul, 2025 Submission checks completed at journal 16 Jul, 2025 First submitted to journal 11 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7102048","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":490109018,"identity":"7ce57e1c-92ed-405b-90e1-6988677a9d9e","order_by":0,"name":"Simone Saringer-Siegl¹²³","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYNACAyidwMAgw8/AwHiwgRQtPJJA5SAtEkRbyGNwgIAW+Qb2h58rCu7Y9UsfYP7woKKWx/j84QcHZzDY1eF00gEeY8kzBs+SZ/YlsEkknDnOY3YjzeDgBoZknLYYMPAwSDYYHE42OMP/jSGx7RhQC4PBwQcMzPgc9vgnSIv9GQbmD4n/jvEY9x//ANRSj9v7BxjMQLbYGfAAfZzYUMNjwJADcthh3A47zGNmCdSSIHGGAeiXYwd4JG7kFBycYXAcFNjYHdbe/vhmw5/D9vw9DMwff9TUyfH3H9/4sKeimh+nw5ghVCLUzMPwYCEI7KE0ztgYBaNgFIyCEQwAlYZXy3rT/QcAAAAASUVORK5CYII=","orcid":"","institution":"University Hospital Salzburg, Paracelsus Medical University","correspondingAuthor":true,"prefix":"","firstName":"Simone","middleName":"","lastName":"Saringer-Siegl¹²³","suffix":""},{"id":490109019,"identity":"880a75f8-5479-42a0-a00b-51252d76b7ee","order_by":1,"name":"Roland Eßl-Maurer¹","email":"","orcid":"","institution":"University Hospital Salzburg, Paracelsus Medical University","correspondingAuthor":false,"prefix":"","firstName":"Roland","middleName":"","lastName":"Eßl-Maurer¹","suffix":""},{"id":490109020,"identity":"662047c1-0af1-4ce5-bcf0-9590a884a004","order_by":2,"name":"Piret Paal","email":"","orcid":"","institution":"Tartu University","correspondingAuthor":false,"prefix":"","firstName":"Piret","middleName":"","lastName":"Paal","suffix":""}],"badges":[],"createdAt":"2025-07-11 13:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7102048/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7102048/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-026-06790-0","type":"published","date":"2026-02-21T15:58:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":103251629,"identity":"d9c2338c-6885-41b2-a3dd-5667ebf4b474","added_by":"auto","created_at":"2026-02-23 16:11:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":530435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7102048/v1/e2971399-25ed-4bcb-ba70-b9426bd03c64.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Navigating the Implementation of Pediatric Palliative Care: Nurses’ Perspectives and the Emerging Role of the Advanced Practice Nurse","fulltext":[{"header":"What is known / What is new","content":"\u003cp\u003e\u003cstrong\u003eWhat is known\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Pediatric palliative care is often misunderstood as synonymous with end-of-life care.\u003cbr\u003e\u0026nbsp;- Implementing PPC in pediatric hospitals requires complex organizational change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is new\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Nurses value PPC as a family-centered model but need emotional and professional support.\u003cbr\u003e\u0026nbsp;- An Advanced Practice Nurse can serve as a facilitator during PPC implementation.\u003cbr\u003e\u0026nbsp;- Participatory approaches effectively identify frontline challenges and attitudes in PPC settings.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eDespite low childhood mortality rates in high-income countries, the prevalence of life-limiting conditions is increasing (1,2). This trend presents significant emotional, organizational, and professional challenges for healthcare providers.\u003c/p\u003e\n\u003cp\u003ePediatric palliative care (PPC) is a holistic, multidisciplinary approach designed to improve quality of life for affected children and their families by addressing medical, psychological, social, and spiritual needs (3,4). It is not limited to end-of-life care but is initiated early in the course of illness and can be delivered alongside curative treatments. The implementation of PPC requires substantial cultural and organizational shifts within hospital settings and challenges traditional care models (5). As such, PPC necessitates not only structural but also professional transformation, including specialized roles and competencies within nursing (5).\u003c/p\u003e\n\u003cp\u003eThe conceptualization and successful integration of PPC is increasingly linked to the expertise of Advanced Practice Nurses (APNs) who possess additional qualifications in pediatric palliative care (4,5,6). These nurses play a critical role in bridging clinical practice, patient advocacy, interprofessional coordination, and ethical reflection. Their advanced training enables them to support complex decision-making processes, provide symptom management, and offer psychosocial guidance to families throughout the illness trajectory (6).\u003c/p\u003e\n\u003cp\u003eAdvanced Practice Nursing has emerged in recent decades as a response to the growing complexity of patient needs and healthcare systems. APNs are registered nurses with graduate-level education and expanded clinical competencies. Their roles include clinical experts, consultants, educators, and leaders in evidence-based practice (7). In pediatric palliative care, APNs contribute to quality improvement by initiating care models, mentoring staff, and ensuring family-centered, ethically grounded interventions (3,4,5,7). These developments align with international efforts to strengthen palliative care services through role differentiation and advanced clinical leadership (2,5,7).\u003c/p\u003e\n\u003cp\u003eIn 2022, the Children’s Center of the University Hospital Salzburg initiated the structured implementation of a PPC concept. As part of this initiative, a dedicated multiprofessional team was established to provide an additional layer of support for patients with life-limiting conditions and their families. This team ensures comprehensive, family-centered care and supports ward-based treatment teams in managing the complex demands of pediatric palliative care. However, little is known about the frontline experiences of nursing staff during such transformations.\u003c/p\u003e\n\u003cp\u003eThis study investigates nurses’ attitudes, emotional burdens, and support needs during the implementation of PPC. The findings aim to guide future role development of Advanced Practice Nurses (APNs) and to refine clinical strategies for integrating PPC into pediatric care.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative, participatory research design was employed to explore the experiences of nurses involved in PPC implementation. This approach enabled nurses to contribute to the research process and express their perspectives openly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at the Children’s Center of the University Hospital Salzburg, a tertiary hospital in Austria. In 2022, the hospital began integrating dedicated PPC beds within two pediatric wards (a Neonatal and Infant Ward and a Parent-Child Ward).\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to recruit registered nurses from both wards. Eligibility criteria included a minimum of six months of professional experience on the respective ward and direct involvement in caring for children with life-limiting conditions. A total of 18 nurses (17 femals, aged 24–55) participated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through four moderated focus group discussions, each comprising 4–5 participants in November 2022. Discussions were conducted in a private meeting room at the hospital and lasted 60–90 minutes.\u003c/p\u003e\n\u003cp\u003eA semi-structured interview guide was developed based on existing literature and clinical insights (8,9). The guide covered the following areas: prior experiences with PPC, perceptions of the new care model, challenges encountered during implementation, and support needs.\u003c/p\u003e\n\u003cp\u003eAll discussions were audio-recorded and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using Braun and Clarke’s six-phase Thematic Analysis (10). The first author performed initial coding and theme generation, supported by peer debriefing with the co-authors. Discrepancies were resolved through consensus discussions.\u003c/p\u003e\n\u003cp\u003eThe analysis process involved: (1) familiarization with the data; (2) generating initial codes; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; and (6) producing the final report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of the Paracelsus Medical University (SS22-0046-0046). Written informed consent was secured from all participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe analysis of the focus group data was conducted following Braun and Clarke’s six-phase approach to Thematic Analysis (3). This method provided a structured and transparent framework for analyzing the data and allowed for a systematic exploration of patterns across the dataset. Through the analysis prozess four main themes and 15 subthemes were identified (Table 1). These themes capture nurses’ experiences, perceptions, and expectations regarding the implementation of PPC.\u003c/p\u003e\n\u003cp\u003eIn the following sections, each theme is presented with illustrative participant quotes and interpretive commentary to convey both the content and the emotional nuances of the findings.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1. Experiences with PPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1a) Longstanding presence of PPC practices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1b) Lack of training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1c) Avoiding the taboo of death\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1d) Need for structured support and training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2. PPC as a New Model of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2a) Conceptual confusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2b) 'Palliative' as a trigger for fear\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2c) Recognition of PPC as life-long care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3. Challenges of Implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3a) Emotional burden\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3b) Managing parental expertise and expectations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3c) Time limitations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4. Expectations Toward PPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4a) Communication strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4b) Role and expectations of the PPC team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4c) Desired support through an APN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Overview of Themes and Subthemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Experiences with Pediatric Palliative Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses shared longstanding experiences in caring for children with complex and life-limiting conditions. Despite the absence of a formal PPC framework in previous years, many participants had been involved in emotionally demanding caregiving situations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"I’ve been working with patients like this for a long time. At the beginning, I often thought they were completely alone, with no support at all.\"\u003c/em\u003e (Group II)\u003c/p\u003e\n\u003cp\u003e1a) Longstanding presence of PPC practices\u003c/p\u003e\n\u003cp\u003eSeveral participants reported that aspects of PPC had long been part of their daily practice, even if not explicitly named as such.\u003c/p\u003e\n\u003cp\u003e1b) Lack of training\u003c/p\u003e\n\u003cp\u003eDespite years of practical experience, nurses described a lack of formal education or conceptual understanding regarding PPC.\u003c/p\u003e\n\u003cp\u003e1c) Avoiding the taboo of death\u003c/p\u003e\n\u003cp\u003eDiscussing death openly remained difficult, both within teams and with families. This avoidance often led to uncertainty in communication.\u003c/p\u003e\n\u003cp\u003e1d) Need for structured support and training\u003c/p\u003e\n\u003cp\u003eParticipants highlighted the absence of structured training and reflection opportunities, especially when dealing with death and dying.\u003c/p\u003e\n\u003cp\u003eThematic summary:\u003cbr\u003e\u0026nbsp;Although many nurses had long cared for severely ill children, the lack of formal training and structured support led to fragmented practices and emotional insecurity. The reluctance to openly address death further compounded this ambiguity. This theme reveals a latent PPC culture lacking systemic anchoring.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: PPC as a New Model of Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile PPC was generally viewed positively, it was perceived as an unfamiliar and emotionally charged concept.\u003c/p\u003e\n\u003cp\u003e2a) Conceptual confusion\u003c/p\u003e\n\u003cp\u003eParticipants expressed uncertainty regarding what constitutes PPC, and where their own responsibilities begin and end.\u003c/p\u003e\n\u003cp\u003e2b) 'Palliative' as a trigger for fear\u003c/p\u003e\n\u003cp\u003eThe term\u0026nbsp;\u003cem\u003e“palliative”\u003c/em\u003e was frequently associated with end-of-life and death, leading to resistance or unease among staff and even affected families.\u003cbr\u003e\u003cem\u003e\"Death was not permitted to occur on our ward either... patients would be transferred elsewhere beforehand.\"\u003c/em\u003e (Group IV)\u003c/p\u003e\n\u003cp\u003e2c) Recognition of PPC as life-long care\u003c/p\u003e\n\u003cp\u003eOver time, many participants began to understand PPC as a long-term, family-centered support approach rather than solely terminal care.\u003c/p\u003e\n\u003cp\u003eThematic summary:\u003cbr\u003e\u0026nbsp;This theme reflects the internal negotiation process within nursing teams as they reframe PPC from a \"death-centered\" to a \"life-supporting\" concept. Language, cultural attitudes, and institutional history played a central role in shaping nurses’ understanding and acceptance of PPC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Challenges of Implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe introduction of PPC triggered emotional, communicative, and organizational tensions within daily practice.\u003c/p\u003e\n\u003cp\u003e3a) Emotional burden\u003c/p\u003e\n\u003cp\u003eParticipants described PPC implementation as emotionally exhausting, particularly due to feelings of helplessness and fear of doing harm.\u003cbr\u003e\u003cem\u003e\"I feel highly insecure and fear that I am providing suboptimal care. I try to avoid this type of care as much as possible.\"\u003c/em\u003e (Group IV)\u003c/p\u003e\n\u003cp\u003e3b) Managing parental expertise and expectations\u003c/p\u003e\n\u003cp\u003eFamilies often arrived well-informed and emotionally involved, which created pressure on nurses to deliver expert and emotionally responsive care.\u003c/p\u003e\n\u003cp\u003e3c) Time limitations\u003c/p\u003e\n\u003cp\u003eParticipants reported that high workload and limited time per patient hampered their ability to fully engage in PPC, particularly in emotionally complex cases.\u003c/p\u003e\n\u003cp\u003eThematic summary:\u003cbr\u003e\u0026nbsp;This theme highlights the emotional and structural barriers nurses face when implementing PPC in a fast-paced hospital environment. It underscores the necessity of institutional support systems to manage emotional stress and provide the resources required for sustainable PPC practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Expectations Toward PPC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLooking forward, nurses formulated clear expectations regarding how PPC should be supported and structured within the institution.\u003c/p\u003e\n\u003cp\u003e4a) Communication strategies\u003c/p\u003e\n\u003cp\u003eParticipants emphasized the importance of regular team communication and reflection opportunities.\u003cbr\u003e\u003cem\u003e\"Communication is key. Even five minutes during lunch to check in — does anyone have an issue? That would help.\"\u003c/em\u003e (Group I)\u003c/p\u003e\n\u003cp\u003e4b) Role and expectations of the PPC team\u003c/p\u003e\n\u003cp\u003eNurses expected PPC teams to be visible, approachable, and actively involved in care planning and team support.\u003c/p\u003e\n\u003cp\u003e4c) Desired support through an APN\u003c/p\u003e\n\u003cp\u003eMany participants saw a designated APN as a key resource person who could bridge clinical practice, emotional support, and educational needs.\u003c/p\u003e\n\u003cp\u003eThematic summary:\u003cbr\u003e\u0026nbsp;This theme articulates nurses’ need for structured communication, accessible expertise, and emotional support. The APN was envisioned as a central figure to coordinate and reinforce PPC within the clinical setting.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study illustrates the complexity of implementing pediatric palliative care (PPC) within a hospital setting. Although nurses acknowledged PPC’s value, the term \u003cem\u003e“palliative”\u003c/em\u003e was frequently associated with death, which contributed to emotional discomfort and initial resistance — a phenomenon consistently reported in the literature (4,11).\u003c/p\u003e\n\u003cp\u003eThe participatory research design was instrumental in uncovering these frontline experiences and emotional barriers. Previous studies emphasize that involving nursing staff early in implementation processes fosters ownership and mitigates resistance (8,11). In this context, the involvement of an Advanced Practice Nurse (APN) emerged as a critical facilitator for easing the transition and supporting both clinical and emotional needs of nursing staff (12).\u003c/p\u003e\n\u003cp\u003eInternational frameworks such as GO-PPaCS (5) and IMPaCCT (1) strongly advocate for early integration of PPC, role clarity, and interprofessional collaboration. Our findings are in line with these recommendations and highlight the urgent need for structured training, institutional emotional support, and dedicated communication strategies to ensure successful PPC implementation.\u003c/p\u003e\n\u003cp\u003eImportantly, this study sheds light on the emotional responses of nurses — ranging from fear and uncertainty to empathy and dedication. Similar patterns have been described by Bergsträsser et al. (12), who noted that lack of preparation and reflection opportunities can result in emotional exhaustion and professional withdrawal. Without adequate institutional support, these risks may jeopardize both staff well-being and care quality (13).\u003c/p\u003e\n\u003cp\u003eEmbedding an APN into PPC implementation can mitigate these risks. As documented by Cormack et al. (8) and Cormack \u0026amp; Dahlin (11), APNs serve not only as clinical experts but also as mentors, role models, and agents of change. They facilitate interdisciplinary collaboration, provide tailored education, and foster psychological resilience among team members (8,11).\u003c/p\u003e\n\u003cp\u003eThe APN’s role in this context emerged as particularly valuable in linking theoretical concepts with everyday clinical practice. In this study, the APN functioned as a “bridge” between conceptual frameworks and clinical reality — a finding supported by international case studies in PPC role development (8,11). The APN contributed to integrating pediatric palliative care into existing care structures, while also promoting reflection, team support, and quality improvement efforts.\u003c/p\u003e\n\u003cp\u003eFurthermore, the desire for a structured, clearly defined APN role expressed by participants resonates with recommendations for advanced nursing practice in PPC outlined by Schober \u0026amp; Affara (9), Streuli et al. (10), and Bergsträsser et al. (12). The APN can effectively counteract conceptual ambiguities, reduce emotional strain, and provide ongoing mentorship — all of which are crucial for sustaining PPC integration in pediatric hospital environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides valuable insights into the experiences of nurses during the early phase of PPC implementation in a tertiary hospital setting. The participatory design enabled the identification of real-world challenges and emotional barriers. However, limitations include the single-center setting and the relatively small sample size, which may limit generalizability. Future research should explore longitudinal perspectives and involve multidisciplinary teams to further inform PPC integration strategies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementing PPC requires more than organizational change; it demands emotional readiness, structured support, and interprofessional collaboration. Nurses play a pivotal role in delivering PPC but need clear guidance, ongoing education, and emotional reassurance.\u003c/p\u003e\n\u003cp\u003eEmbedding an Advanced Practice Nurse (APN) within PPC teams has the potential to significantly enhance implementation success. The APN can serve as a clinical expert, facilitator of interprofessional collaboration, and emotional support for nursing staff. As such, the structured integration of an APN should be considered a key component of sustainable PPC implementation strategies in pediatric healthcare settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAPN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdvanced Practice Nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdvanced Nursing Practice\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePediatric Palliative Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThematic Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthical Approval\u003c/h2\u003e\u003cp\u003e This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the institutional ethics committee of the Paracelsus Medical University (SS22-0046-0046).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from all individual participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflict of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.S wrote the main manuscript text and all authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data is password-protected and stored in a neutral location. It is not possible for anyone to draw conclusions about a person based on the written group discussion. All anonymized data of the group discussions and their transcription as well as the declarations of consent are secured and stored by the researcher against unauthorized access.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCraig F, Abu-Saad Huijer H, Benini F, Kuttner L, Wood C, Feraris PC. IMPaCCT: standards for paediatric palliative care in Europe. Eur J Palliat Care. 2007;14:109–114.\u003c/li\u003e\n\u003cli\u003eBenini F, Papadatou D, Bernadá M, et al. International standards for pediatric palliative care: The GO-PPaCS project. J Palliat Med. 2022;25:698–707. doi:10.1089/jpm.2021.0428\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic Analysis: A Practical Guide. London: SAGE Publications; 2022.\u003c/li\u003e\n\u003cli\u003eZernikow B, Michel E, Garske D. Pädiatrische Palliativversorgung: Konzepte, Herausforderungen und Entwicklungen. Z Kinder Jugendpsychiatr Psychother. 2013;41:399–405.\u003c/li\u003e\n\u003cli\u003eStreuli JC, von Mengershausen A. Ethical challenges in pediatric palliative care: A literature review. Palliat Med. 2021;35:457–465.\u003c/li\u003e\n\u003cli\u003eThaxton, C.A. \u0026amp; Neubauer, L. (2016). The Role of the Pediatric Palliative Advanced Practice Registered Nurse. In: C. Dahlin, P. Coyne \u0026amp; B. Ferrel (Hrsg.). \u003cem\u003eAdvanced Practice Palliative Nursing\u003c/em\u003e. (S. 545–551). New York: Oxford University Press.\u003c/li\u003e\n\u003cli\u003eTracy, MF. \u0026amp; Sendelbach, S. (2019). The Clinical Nurse Specialist. In M.F. Tracy \u0026amp; E.T. O’Grady (Hrsg.) \u003cem\u003eAdvanced Practice Nursing: An integrative approach.\u003c/em\u003e S. 343–373. St. Louis, Missouri: Elsevier\u003c/li\u003e\n\u003cli\u003eCormack M, Devaney C, Rainsford S. Role development of the Advanced Nurse Practitioner in paediatric palliative care: A review. Child Care Health Dev. 2022;48:163–172.\u003c/li\u003e\n\u003cli\u003eSchober M, Affara F. Advanced Nursing Practice. Oxford: Blackwell Publishing; 2008.\u003c/li\u003e\n\u003cli\u003eStreuli J, Bergsträsser E, Flury M, Satir A. Kinder-Palliativmedizin Essentials. Bern: Hogrefe Verlag; 2018.\u003c/li\u003e\n\u003cli\u003eCormack CL, Dahlin C. The Pediatric Palliative APRN: Leading the Future. J Pediatr Health Care. 2022;36:381–387. doi:10.1016/j.pedhc.2022.01.005\u003c/li\u003e\n\u003cli\u003eBergsträsser E, Inglin S, Abbruzzese R, et al. The needs of professionals in the palliative care of children and adolescents. Eur J Pediatr. 2012;172:111–118. doi:10.1007/s00431-012-1880-8\u003c/li\u003e\n\u003cli\u003eRoland J, Lambert M, Shaw A, et al. The children’s palliative care provider of the future: A blueprint to spark, scale and share innovation. Imperial College London; 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pediatric palliative care, nursing attitudes, participatory research, implementation, support needs","lastPublishedDoi":"10.21203/rs.3.rs-7102048/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7102048/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003e This study explores nurses\u0026rsquo; attitudes and support needs during the implementation of a pediatric palliative care (PPC) concept at a tertiary children\u0026rsquo;s hospital in Austria.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003e A qualitative, participatory research design was employed. Four moderated focus groups involving 18 nurses from two PPC-integrated wards were conducted. Data were transcribed verbatim and analyzed using Braun and Clarke\u0026rsquo;s Thematic Analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eAnalysis revealed four themes: (1) experiences with PPC, (2) PPC as a new model of care, (3) challenges of implementation, and (4) expectations toward PPC. While nurses viewed PPC as a valuable, family-centered concept, they reported emotional strain, time constraints, and communication barriers. The term \u0026ldquo;palliative\u0026rdquo; was frequently associated with death, highlighting the need for cultural reframing and education.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eSuccessful PPC implementation requires emotional readiness, interprofessional collaboration, and dedicated support structures. Nurses expressed a strong desire for structured guidance, training, and the presence of an Advanced Practice Nurse (APN) to provide clinical and emotional support.\u003c/p\u003e","manuscriptTitle":"Navigating the Implementation of Pediatric Palliative Care: Nurses’ Perspectives and the Emerging Role of the Advanced Practice Nurse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 15:31:21","doi":"10.21203/rs.3.rs-7102048/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-12T10:48:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-10T14:31:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155873700488712979033450983928539902952","date":"2025-08-27T13:17:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T12:51:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259274303784132529295177278497311036674","date":"2025-07-29T10:21:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298160747639663254136504019987116996561","date":"2025-07-29T03:07:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-21T19:42:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-17T04:20:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T03:58:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2025-07-11T13:07:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a04ed312-16d2-4b8a-bbaa-52502a6bc30c","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:06:54+00:00","versionOfRecord":{"articleIdentity":"rs-7102048","link":"https://doi.org/10.1007/s00431-026-06790-0","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2026-02-21 15:58:17","publishedOnDateReadable":"February 21st, 2026"},"versionCreatedAt":"2025-07-25 15:31:21","video":"","vorDoi":"10.1007/s00431-026-06790-0","vorDoiUrl":"https://doi.org/10.1007/s00431-026-06790-0","workflowStages":[]},"version":"v1","identity":"rs-7102048","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7102048","identity":"rs-7102048","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}