The Forgotten Phase of Resuscitation
The resuscitation team leader delivers the final assessment: an unshockable rhythm, blood gases incompatible with life. No further interventions will alter the outcome. The family has been informed. Time of death is recorded. One by one, staff leave the room.
One person remains, the resus nurse. Minutes stretch into hours. The medical team come and goes, the police attend and leave, questions are asked, and paperwork is completed. Throughout it all, the nurse stays, caring for the child and supporting the family until the final moments before transfer to the mortuary.
But what happens to the nurse in these hours? This is the forgotten phase of resuscitation, and psychological safety is central to surviving it.
Why It Matters
A paediatric cardiac arrest ending in death is profoundly traumatic. In the UK, when a death is sudden and unexpected, national guidance for the investigation of sudden unexpected death in infancy requires structured processes, including careful management of the child prior to mortuary transfer. In practice, this responsibility frequently falls to the paediatric emergency nurse.
While these processes safeguard families and ensure appropriate investigation, the emotional impact on staff is less visible. Paediatric critical care professionals describe sustained emotional burden, moral distress, and organisational challenges that affect wellbeing. Repeated exposure to morally injurious events, including traumatic deaths and ethically complex situations, is associated with anxiety, depression and symptoms of post-traumatic stress among healthcare staff.
A workplace culture that actively fosters psychological safety, where staff feel able to recognise emotional impact, ask for support and speak candidly without fear of blame, is essential. Evidence from paediatric critical care highlights that meaningful improvements in staff wellbeing depend on organisational culture, consistent leadership behaviours and structured support systems rather than individual resilience alone.
Psychological Safety in Context
Psychological safety is not about resilience or “coping better”. It is about coping systems and strategies. When staff feel able to articulate distress, ask for help and reflect without stigma, emotional processing is more adaptive.
Psychological safety reflects this environment: a setting in which staff feel safe to speak up, acknowledge mistakes and share concerns without fear of negative consequences.
Research in paediatric critical care highlights that wellbeing is shaped not only by exposure to traumatic events but by workplace culture and leadership response. During the COVID-19 pandemic, nurses working in paediatric critical care described emotional exhaustion, ethical strain and the cumulative impact of repeated high-stakes care. These findings reinforce that exposure alone does not determine outcomes; support structures for the team matter.
Importantly, interventions grounded in behavioural science have demonstrated that structured, evidence-based approaches can strengthen staff wellbeing in paediatric critical care environments. Psychological safety must therefore be embedded deliberately, rather than assumed.
The Emotional Labour of Paediatric Death
Caring for a child who dies is uniquely distressing. Although the resuscitation may end, the nurse’s role often continues, supporting grieving parents, siblings and other family members, liaising with police or social services, completing documentation and preparing the child for transfer.
Qualitative research exploring paediatric critical care staff experiences highlights moral distress, which arises when professionals feel unable to deliver the standard of care they believe is ethically right, or when organisational pressures conflict with professional values.
Repeated exposure to ethically challenging situations can cause moral distress, which negatively affects nurses’ wellbeing, job satisfaction and retention, highlighting the importance of structured support systems in high-stakes paediatric care. National research on moral injury among healthcare workers further demonstrates that repeated exposure to ethically challenging events can have measurable psychological consequences. Moral distress in paediatric nursing is complex and multidimensional, encompassing emotional, psychological and ethical dimensions, all of which can affect wellbeing, job satisfaction and retention.
Healthcare professionals involved in adverse events often experience prolonged distress. Qualitative studies show lasting psychological impact and turnover intentions among nurses exposed to second victim experiences. The burden is cumulative, as each event rarely occurs in isolation. Without adequate acknowledgement and structured support, emotional residue builds. From personal experience, being asked by families not to leave their child or having to prevent relatives from entering mortuary spaces compounds the weight already carried. These moments remain with staff long after the clinical event has concluded.
When Psychological Safety Is Present
When psychological safety exists, the aftermath looks different.
Leaders check in. Colleagues remain visible. Time for reflection is protected. Access to support is clear and stigma-free. NHS guidance on help and support after traumatic events emphasises the importance of timely psychological support pathways and clear escalation routes.
In organisations where wellbeing interventions have been systematically developed and integrated, staff report greater clarity around support mechanisms and improved engagement with reflective practice. Research exploring staff wellbeing in paediatric critical care consistently highlights that leadership behaviour, communication and visible cultural commitment to staff welfare influence how trauma is processed.
Psychological safety does not remove grief, emotional trauma or distress. It distributes it. It signals that emotional responses are legitimate and anticipated, rather than signs of weakness.
When Psychological Safety Is Absent
Without psychological safety, staff may suppress emotional responses to continue functioning. Over time, this suppression increases vulnerability to burnout and moral injury. Paediatric critical care staff describe feeling isolated when support is informal, inconsistent or dependent on individual personalities rather than structured systems.
Where wellbeing is framed as individual resilience rather than organisational responsibility, staff may internalise distress as personal inadequacy. This is neither fair nor sustainable.
Evidence-informed interventions in paediatric critical care demonstrate that organisational change, rather than individual coping strategies alone, is required to meaningfully improve wellbeing
Practical Strategies for Paediatric Emergency Settings
Psychological safety doesn’t appear because we say it should. It grows from small, deliberate actions repeated consistently with the team.
Start with the individual
After a child dies, the expectation is often to move on. Another patient. Another task. Another shift.
But even five minutes to step away, breathe, having a drink and gathering thoughts can interrupt the physiological stress response. Giving staff explicit permission to pause matters. So does normalising emotional reactions. Saying, “That was tough, how are you doing?” should feel routine, not exceptional.
Build it into the team
Teams set the tone. A brief, structured check-in after a resuscitation, even two minutes of shared acknowledgement, can transform isolation into collective processing. Evidence from paediatric critical care shows that embedding structured debrief opportunities into routine practice strengthens wellbeing and engagement (4).
It does not have to be formal or lengthy. It does have to be intentional.
Make leadership visible
When senior clinicians stay for the aftermath, not just the bulk of the arrest, it sends a powerful message. Leadership behaviours shape culture. Staff are more likely to speak openly when leaders model openness themselves.
Psychological safety is rarely created by policy alone! It is created on modelled behaviour.
Think Organisational, Not Individual
Support for staff cannot depend on who happens to be on shift. Organisations must provide clear and accessible pathways for psychological support in accordance with NHS guidance. Beyond immediate crisis response, evidence-based wellbeing interventions tailored to paediatric critical care should be implemented, with staff experiences actively reviewed to inform ongoing service development. A recent qualitative systematic review highlights that healthcare professionals worldwide frequently experience “second victim” distress following adverse events, reinforcing the need for systemic support alongside individual coping strategies. These measures are essential: they protect workforce sustainability, reduce moral injury, and ultimately safeguard patient care.
Key Points
Psychological safety does not end when CPR stops.
The emotional labour of paediatric death often falls heaviest on those left with the child & family.
Moral distress is a predictable response to repeated ethically complex care
Leadership behaviour and organisational culture strongly influence staff wellbeing
Structured, evidence-informed support can mitigate harm and strengthen teams
Back in that resuscitation room, the nurse remains with the family, hours after the child’s death.
If psychological safety is present, they are not alone. The organisation has anticipated the impact. Support is structured. Leaders are visible. Grief and emotional weight is acknowledged rather than absorbed in silence.
The child’s dignity is preserved. The family is supported. And the nurse is supported too.
If we care about children and families, we must also care for the professionals who remain when everyone else has gone.
References
Royal College of Pathologists. New guidelines for the investigation of sudden unexpected death in infancy launched [Internet]. Available from: https://www.rcpath.org/discover-pathology/news/new-guidelines-for-the-investigation-of-sudden-unexpected-death-in-infancy-launched.html
Yeter E, Bhamra H, Butcher I, Morrison R, Donnelly P, Shaw R. Managing well-being in paediatric critical care: a multiperspective qualitative study of nurses’ and allied health professionals’ experiences. BMJ Open [Internet]. 2024 May 1;14(5):e084926.
Williamson V, Lamb D, Hotopf M, Raine R, Stevelink S, Wessely S, et al. Moral injury and psychological wellbeing in UK healthcare staff. J Ment Health [Internet]. 2023 Mar 8;32(5):890–8.
Shaw RL, Butcher I, Webb S, Duncan HP, Morrison R. Building evidence-based interventions to improve staff well-being in paediatric critical care using the behaviour change wheel. Nurs Crit Care [Internet]. 2025 Jan 8;30(4):e13228.
Pountney J, Butcher I, Donnelly P, Morrison R, Shaw RL. How the COVID-19 crisis affected the well-being of nurses working in paediatric critical care: a qualitative study. Br J Health Psychol [Internet]. 2023 Mar 30;28(4):914–29. Available from: https://doi.org/10.1111/bjhp.12661
NHS England — London. Help and support after a traumatic event [Internet]. Available from: https://www.england.nhs.uk/london/our-work/mental-health-support/help-and-support/
Lim SH, Zainal H, Lee LJ, Sunari RNB, Choh ACL, Teo KY, et al. Second victim experiences and impact among acute care nurses: An exploratory study. International Nursing Review [Internet]. 2024 Jun 7;72(1):e12999.
Miranda ACR, Fernandes SD, Ramos S, Nunes E, Fabri J, Caldeira S. Moral distress of nurses working in paediatric healthcare settings. Healthcare [Internet]. 2024 Jul 8;12(13):1364. Available from: https://doi.org/10.3390/healthcare12131364
Deng Y, Mo B, Xu B, Wang L, Lai J, Zhao C. The second victim of adverse events in health care: A systematic review of qualitative research. International Journal of Nursing Studies [Internet]. 2025 Oct 7;173:105248.
Edmondson A. Psychological safety and learning behavior in work teams. Administrative Science Quarterly [Internet]. 1999 Jun 1;44(2):350–83. Available from: https://doi.org/10.2307/2666999
Kangasniemi M, Pakkanen P, Korhonen A. Professional ethics in nursing: an integrative review. Journal of Advanced Nursing [Internet]. 2015 Jan 19;71(8):1744–57. Available from: https://doi.org/10.1111/jan.12619
