Objectives: We aimed to explore the experiences, challenges, and coping strategies of nurses working in pediatric organ transplant clinics in Türkiye. We investigated emotional stressors, ethical dilemmas, communication challenges, and the effectiveness of institutional support to address these challenges.
Materials and Methods: A qualitative descriptive study design was employed. Data were collected through semi-structured face-to-face interviews with 20 organ transplant nurses from various hospitals in Türkiye. We used a purposive sampling method to select the participants. We used qualitative data analysis software (NVivo; version 12) to identify recurring themes related to emotional distress, ethical concerns, communication issues, and coping strategies. Ethical approval was obtained from the relevant institutional review board, and informed consent was secured from all participants.
Results: Thematic analysis revealed 4 main categories: emotional challenges, ethical dilemmas, communication challenges, and coping strategies. Nurses reported experiencing high levels of stress and burnout due to prolonged exposure to critically ill children. Ethical dilemmas related to organ allocation decisions created additional moral distress. Communication challenges were primarily linked to breaking bad news to patients’ families and managing unrealistic expectations from families. Coping mechanisms included reliance on peer support, use of previously established personal resilience strategies, and access to institutional psychological support.
Conclusions: Pediatric organ transplant nurses encounter important emotional, ethical, and communication challenges. Enhancing institutional support structures, providing targeted psychological counseling, and improving communication training programs could alleviate these concerns and thereby improve both nurse well-being and patient care outcomes. Future multicenter studies would expand the generalizability of these findings and identify best practices for institutional support of transplant nurses. Key words: Coping strategies, Emotional challenges, Nursing experiences, Pediatric organ transplantation, Qualitative research

Introduction
Organ transplant is a critical medical advancement that has significantly improved survival rates and quality of life for pediatric patients with end-stage organ failure. Despite medical advancements, pediatric organ transplant presents unique challenges that affect both patients and health care providers, particularly nurses who play a pivotal role in the care process. Pediatric patients undergoing organ transplant require specialized care that addresses not only their medical needs but also the patients’ psychological and emotional well-being.¹ One of the foremost challenges in pediatric organ transplant is the limited availability of donor organs. The scarcity of pediatric organ donors contributes to prolonged wait times, which can lead to the deterioration of patients’ health before transplant.² This situation places immense pressure on nurses, who must manage both the medical complexities and the emotional distress of their young patients and patients’ families. In addition, the ethical dilemmas associated with organ allocation often create moral distress among nurses. Nurses witness firsthand the difficult decisions regarding allocation of organs to recipients, and such experiences can lead to professional and emotional challenges for nurses.³ The role of nurses in pediatric organ transplant extends beyond clinical care. Nurses serve as intermediaries between patients, families, and the multidisciplinary health care team. Effective communication between nurses and patients’ families is crucial, yet studies have shown that many nurses struggle with delivering difficult news to families.^4,6 Breaking bad news, discussing the uncertainty of organ availability, and managing families’ expectations require not only medical expertise from nurses but also emotional intelligence and communication skills. A lack of structured training in these areas often exacerbates the emotional distress experienced by nurses.⁷ Moreover, pediatric transplant nurses frequently experience high levels of occupational stress and high rates of the workplace syndrome known as burnout. A previously published systematic review has found that transplant nurses report significantly higher rates of emotional exhaustion compared with rates reported by nurses in other medical fields.⁸ The high-stakes nature of organ transplant, coupled with the emotional distress of caring for critically ill children, contributes to increased rates of compassion fatigue and job dissatisfaction. Psychological support programs and resilience training have been recommended as essential interventions to mitigate these adverse effects.⁹ In the Turkish context, cultural and religious beliefs on organ donation further complicate the transplant process. Many families are hesitant to consent to organ donation due to misconceptions based in religious beliefs and perceptions of societal stigma 10 Nurses, therefore, play a crucial role to educate families about the benefits of organ donation and address family concerns. Research indicates that public awareness campaigns and hospital-led education programs can positively influence donation rates and alleviate some of the negative experiences reported by transplant nurses.¹¹ Despite these challenges, pediatric transplant nursing remains a highly rewarding field. Nurses witness the transformative effect of successful organ transplants on children’s lives, which serves as a powerful motivator. However, there remains a pressing need for systemic improvements, including better psychological support for nurses, structured training in ethical decisions, and enhanced communication strategies. Institutional attention to these issues will not only improve nurses’ well-being but also contribute to higher standards of patient care in pediatric transplant. Our study aimed to explore the perspectives and experiences of nurses working in pediatric organ transplant clinics in Türkiye. By identifying the key challenges experienced by these nurses and the strategies they employ to cope with these challenges, our findings will contribute to policy recommendations for improvements in nurse support systems and patient care outcomes in pediatric organ transplant.

Materials and Methods

Ethics
This study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki has been approved by the Ethics Committee of Burdur Mehmet Akif Ersoy University. Ethical approval was obtained under the protocol No. GO2025/1332 on April 16, 2025. All participants were informed about the purpose of the study, and informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were assured of their right to withdraw from the study at any time without any penalty. Data confidentiality and anonymity were strictly maintained throughout the study process.

Design
This study employed a qualitative descriptive research design to explore the lived experiences of nurses caring for pediatric organ transplant patients. A qualitative approach was chosen to capture in-depth insights into the emotional, ethical, and professional challenges experienced by nurses. This method allowed for a detailed analysis of personal experiences, perceptions, and coping strategies through thematic analysis.

Recruitment and sample method
We used a purposive sampling method to recruit participants from organ transplant clinics in hospitals in Türkiye. Inclusion criteria were (1) registered nurses with at least 1 year of experience in pediatric organ transplant, (2) direct involvement in patient care, and (3) willingness to participate voluntarily. A total of 20 nurses were interviewed, to ensure data saturation.

Data collection
Semi-structured face-to-face interviews were conducted with each participant. Interviews lasted between 30 and 60 minutes and were recorded with participant consent. A standardized interview guide was used, including open-ended questions focused on emotional challenges, communication experiences, ethical dilemmas, and coping strategies. Participants were encouraged to share detailed personal reflections to enrich the qualitative data.

Procedure and analysis
Interviews were transcribed verbatim and analyzed using qualitative data analysis software (NVivo; version 12). Thematic analysis was conducted according to the method of Braun and Clarke, as follows¹²: (1) familiarization with data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the final report. Two researchers independently coded the transcripts to ensure reliability, and discrepancies were resolved through discussion.¹³

Results

Demographic characteristics
The demographic analysis of the 20 nurses revealed that most participants were female (90%), with an average age of 34.5 years. Their professional experience varied, with 20% having less than 5 years, 40% having between 5 and 10 years, and 40% having more than 10 years of experience in pediatric organ transplant. Regarding educational background, 60% of participants held a bachelor’s degree, 30% had a master’s degree, and 10% had a doctoral degree. In terms of workplace distribution, 50% of the participants were employed in university hospitals, 30% in public hospitals, and 20% in private hospitals. These findings indicate, generally, that pediatric organ transplant nurses are experienced, well-educated professionals. However, further analysis will explore how factors such as years of experience and hospital type influence their professional challenges and coping strategies (Table 1).

Thematic analysis
The thematic analysis of the interviews revealed 4 major categories: emotional challenges, ethical dilemmas, communication challenges, and coping strategies. Nurses reported acute emotional distress due to prolonged exposure to critically ill children and patients’ families, leading to stress, anxiety, and burnout. Ethical dilemmas, particularly with regard to organ allocation and professional boundaries, created moral distress and emotional strain. Communication challenges emerged as a critical issue, with nurses struggling to deliver bad news and manage families’ unrealistic expectations about transplant outcomes. To cope with these challenges, nurses relied on peer support, personal resilience strategies, and, to a lesser extent, institutional psychological support. The following sections provide a detailed breakdown of each category, including subthemes and representative participant statements (Table 2).

Emotional challenges
Stress and anxiety. Nurses frequently experience emotional distress due to the intensity of pediatric organ transplant cases. The emotional toll is overwhelming; watching children suffer is heartbreaking. (Nurse 1) It’s hard to stay strong every day when you see families in despair. (Nurse 2) Burnout. Many nurses report experiences of physical and mental exhaustion due to workload and emotional strain.

I feel exhausted, both physically and mentally, after every shift. (Nurse 7)
I sometimes think about leaving this job because it’s too much to handle. (Nurse 9)

Ethical dilemmas
Organ allocation. The decision-making process for allocation of scarce organs creates ethical dilemmas for nurses. Deciding who gets a transplant is emotionally challenging. (Nurse 4) We try to be fair, but sometimes there are no easy choices. (Nurse 3) Professional boundaries. Although nurses are trained to maintain appropriate emotional detachment, they often form bonds with patients. We try to detach, but it’s hard not to get emotionally involved. (Nurse 10) Seeing a child lose their battle is devastating. (Nurse 5)

Communication challenges
Breaking bad news. Communicating updates of unfavorable patient status to families is one of the most distressing aspects of the job. Telling parents about complications is the hardest part of my job. (Nurse 3) You can never truly prepare for the reactions of grieving families. (Nurse 6) Managing family expectations. Families often have unrealistic expectations regarding transplant success rates, and nurses are challenged to maintain effective communication within the context of these expectations.. Families often believe we can do miracles, but sometimes we can’t. (Nurse 8) Managing parental hope while being honest is a delicate balance. (Nurse 2)

Coping strategies
Peer support. To cope with emotional stress, many nurses rely on their colleagues for support.

Talking to colleagues who understand helps me deal with stress. (Nurse 5)

We share experiences to lighten the emotional load. (Nurse 1)
Institutional support. Nurses suggest that there is a need for their institutions to provide more structured psychological support programs. More psychological support should be provided for nurses. (Nurse 6) Workshops on emotional resilience could help us manage stress better. (Nurse 4)

Discussion
The findings of our study align with previous research indicating that pediatric transplant nurses experience important emotional, ethical, and communication challenges. The emotional distress of caring for critically ill children and witnessing the distress of patients’ families can lead to high levels of stress, anxiety, and burnout among nurses.^1,14 Burnout has been widely reported among health care professionals in high-stress environments, particularly in transplant units, where nurses often experience feelings of helplessness and frustration.^8,15 The findings suggest that structured psychological support programs and resilience training could help mitigate these effects. Ethical dilemmas, particularly those concerning organ allocation, remain a key challenge for nurses working in pediatric transplant. Nurses frequently encounter moral distress due to organ allocation decisions, especially in cases where multiple patients are in need but resources are scarce.³ This aligns with studies published in the international literature, which have highlighted the importance of ethical training and support systems to help nurses navigate these dilemmas effectively.^16,17 Communication barriers were another major theme identified in this study. Nurses often struggle with breaking bad news to families and managing unrealistic expectations about transplant outcomes. Previous research has emphasized the need for structured communication training for health care professionals working in critical care settings.^18,19 Studies have suggested that the use of standardized communication protocols and simulation-based training can improve nurses’ confidence and ability to handle difficult conversations with families.⁹ Coping strategies employed by nurses included reliance on peer support and institutional support. Our findings indicate that nurses rely heavily on their colleagues for emotional support, which is consistent with research showing that peer support networks play a crucial role to reduce stress and prevent burnout in health care settings.^20,21 However, institutional support, including access to counseling services and professional development opportunities, was found to be lacking. Investment in these areas could improve job satisfaction and overall well-being among transplant nurses.

Limitations
This study had several limitations. First, the research was conducted in a single region of Türkiye, which limits the generalizability of the findings to other health care settings. Future multi-center studies could capture a broader range of experiences. Second, self-reported data may be subject to recall bias or social desirability bias, as participants may not have fully disclosed their feelings and experiences. Last, although our use of thematic analysis has provided valuable insights, a longitudinal study design could offer a deeper understanding of how these challenges and coping behaviors evolve over time. Despite these limitations, this study provides important insights into the experiences of pediatric transplant nurses and highlights areas for improvement in psychological support, ethical training, and communication strategies. Addressing these issues through targeted interventions could enhance nurse well-being and ultimately improve patient care outcomes in pediatric organ transplant.

Conclusion
This study provides a comprehensive exploration of the experiences and challenges reported by pediatric organ transplant nurses in Türkiye. The findings highlight the profound emotional distress, ethical dilemmas, and communication difficulties that nurses encounter in their daily practice. Emotional distress, stemming from witnessing critically ill children and their families in distress, is an important concern that contributes to stress and burnout. Ethical challenges, particularly in organ allocation, create moral dilemmas that require structured ethical guidance and decision-making frameworks. Communication challenges that arise between nurses and patients’ families, such as breaking bad news and managing unrealistic expectations, emphasize the need for enhanced training for nurses with regard to patient and family communication strategies. Our study also emphasizes the critical role of effective coping strategies to mitigate the potential negative effects of these challenges. Peer support emerged as a vital resource, allowing nurses to share their experiences and seek emotional validation. Institutional support, although lacking in some areas, has the potential to play a crucial role to foster resilience among nurses. Addressing these gaps through targeted interventions such as mental health support programs, ethical decision-making workshops, and communication training could significantly improve the well-being of nurses and thereby facilitate higher quality of care provided to their pediatric transplant patients. Given the limitations of this study, including its regional focus and reliance on self-reported data, future multi-center studies across different health care settings would facilitate a more comprehensive understanding of these challenges. Future longitudinal studies to assess the long-term effects of emotional burden and coping strategies on nurses’ professional and personal lives could provide deeper insights. Furthermore, policy-level interventions aimed to improve working conditions and psychological support for transplant nurses should be prioritized. Ultimately, recognizing the unique challenges experienced by pediatric organ transplant nurses and addressing their concerns are essential to ensure both nurse well-being and optimal patient outcomes. Strengthening institutional support systems and fostering a culture of resilience within transplant units could lead to a more sustainable and compassionate health care environment.