Healthcare professionals in Israel work within a system shaped by chronic strain, recurring security threats, and continuous organizational pressures. The Iron Swords War of October 2023 (the Israel-Gaza war, referred to in Israel as “Iron Swords”) intensified these conditions, heightening workloads, emotional vulnerability, and complex ethical dilemmas. The country’s multicultural workforce, including Jewish, Arab, and Druze professionals, added another layer of tension but also revealed moments of solidarity and shared commitment during extreme conditions.
Research question and aim
The study examines how healthcare professionals experienced their work during the war, focusing on operational strain, ethical tensions, emotional burdens, and team dynamics in diverse clinical settings.
Research design
A qualitative abductive design was used to explore emergent themes alongside existing theoretical insights on crisis management, ethics, and healthcare work in conflict zones.
Participants and research context
Thirty four healthcare professionals from public hospitals across Israel participated. All interviews explored experiences during 2023–2024 in clinical environments directly affected by wartime demands.
Findings
The findings reveal five key themes: (1) Structural and Operational Strain Exposed; (2) Professional Commitment versus Ethical Strain; (3) Emotional Burden and Identity Blurring; (4) Team Dynamics: Solidarity, Fragmentation, and Adaptation; and (5) Reaffirming the Moral Identity of the Healthcare System. The study highlights the psychological toll on professionals, including moral distress and moral injury, as they balanced patient care, personal safety, and professional ethics within this diverse workforce.
Conclusions
The findings underscore the urgent need for structural reforms and institutional support mechanisms that address both operational strain and the emotional and moral burdens faced by healthcare professionals in crisis-prone environments. While rooted in the Israeli context, the study offers broader insights for healthcare systems operating under conditions of chronic strain, political tension, or conflict.
HaakenstadAIrvineCMSKnightM, et al.Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019. BMJ Glob Health2022; 7: e009316. Available from. https://gh.bmj.com/content/7/6/e009316
4.
SøvoldLENaslundJAKousoulisAA, et al.Prioritizing the mental health and well-being of healthcare workers: an urgent global public health priority. Front Public Health2021; 9: 679397. https://doi.org/10.3389/fpubh.2021.679397Available from.
5.
ShanafeltTDWestCPSinskyC, et al.Changes in burnout and satisfaction with work-life integration in physicians during the COVID-19 pandemic. Mayo Clin Proc2022; 97(12): 2248–2258. Available from. https://doi.org/10.1016/j.mayocp.2022.09.002
6.
Naamati-SchneiderLArazi-FadlonMDaphna-TekoahS. Navigating moral and ethical dilemmas in digital transformation processes within healthcare organizations. Digit Health2024; 10: 10. https://doi.org/10.1177/20552076241260416
7.
Naamati-SchneiderLArazi-FadlonMDaphna-TekoahS. Strategic technological processes in hospitals: conflicts and personal experiences of healthcare teams. Nurs Ethics2024: 10.
8.
MelnikovSBlaerYShaimanL, et al.To command is to serve: senior leadership and policy making predict hospital ward functioning in emergency. J Nurs Manag2019; 27(4): 697–705. https://doi.org/10.1111/jonm.12734
HeklayACohenRKrigerH, et al.Healthcare professions workforce 2022 [Internet]. Jerusalem: Ministry of Health, Information Department, Division of Medical Technologies, Information, and Research, 2023.
13.
RosenBMiaariS. Arab representation in Israeli healthcare professions: achievements, challenges and opportunities. Isr J Health Pol Res2025; 14(7): 7. https://doi.org/10.1186/s13584-024-00663-3
14.
JoachimMVAtia JoachimDKornL, et al.Emotional resilience and sense of danger among doctors in hospitals during periods of heightened tensions and warfare in Israel. Isr J Health Pol Res2024; 13: 68. https://doi.org/10.1186/s13584-024-00655-3
15.
Bou-KarroumLEl-HarakehAKassamanyI, et al.Health care workers in conflict and post-conflict settings: systematic mapping of the evidence. PLoS One2020; 15(5): e0233757. https://doi.org/10.1371/journal.pone.0233757
16.
WilsonMAShayAHarrisJI, et al.Moral distress and moral injury in military healthcare clinicians: a scoping review. AJ Focus2024; 3(2): 100173. https://doi.org/10.1016/j.focus.2023.100173
17.
DeanWTalbotSDeanA. Reframing clinician distress: moral injury not burnout. Fed Pract2019; 36(9): 400–402.
GriffinBJPurcellNBurkmanK, et al.Moral injury: an integrative review. J Trauma Stress2019; 32(3): 350–362. https://doi.org/10.1002/jts.22362
20.
NeriaYPickoverA. Commentary on the special issue on moral injury: advances, gaps in literature, and future directions. J Trauma Stress2019; 32(3): 459–464. https://doi.org/10.1002/jts.22402
21.
ČartolovniAStoltMScottPA, et al.Moral injury in healthcare professionals: a scoping review and discussion. Nurs Ethics2021; 28(5): 590–602. https://doi.org/10.1177/0969733020966776
22.
MolendijkTVerkorenWDrogendijkA, et al.Contextual dimensions of moral injury: an interdisciplinary review. Mil Psychol2022; 34(6): 742–753. https://doi.org/10.1080/08995605.2022.2035643
23.
SadhaanABrownMMcLaughlinD. Registered nurses' views and experiences of delivering care in war and conflict areas: a systematic review. Healthcare (Basel)2022; 10(11): 2168. https://doi.org/10.3390/healthcare10112168
24.
AgazioJGoodmanPOpanubiO, et al.Ethical issues encountered by military nurses during wartime. Annu Rev Nurs Res2016; 34: 227–246. https://doi.org/10.1891/0739-6686.34.227
25.
Gavriely-NuriD. The pretty war: representations of war in Israeli culture, 1967–1973. Democr Cult2007; 11: 51–76, Available from. https://www.jstor.org/stable/24143597
SternYZSagiACohenSA (eds). Democratic Culture, 4–5: Israel and Her Army [Internet], 2001. [cited 2025 Apr 9]. Available from. https://www.jstor.org/stable/i24141587
28.
Ben-AriE. Military, state, and society in Israel: theoretical and comparative perspectives. : Routledge, 2018.
29.
KertcherCTurinO. ‘Siege mentality’ reaction to the pandemic: Israeli memes during Covid-19. Postdigit Sci Educ2020; 2(3): 581–587. https://doi.org/10.1007/s42438-020-00175-8
30.
Gavriely-NuriD. The normalization of war in Israeli discourse, 1967–2008. : Lexington Books, 2012.
31.
MarcianoAYadlinA. Media coverage of COVID-19 state surveillance in Israel: the securitization and militarization of a civil-medical crisis. Media Cult Soc, 2021. DOI: 10.1177/01634437211037008.
32.
Naamati-SchneiderLGabayG. Metaphors of war in effective and ineffective coping of medical directors of COVID-19 wards in public hospitals. Front Public Health2022; 10: 830266. https://doi.org/10.3389/fpubh.2022.830266
IslasIGBrantleyEPortela MartinezM, et al.Documenting Latino representation in the US health workforce: study examines Latino representation in the US health workforce. Health Aff2023; 42(7): 997–1001. https://doi.org/10.1377/hlthaff.2022.01348
36.
HammondJBrooksJ. The World Trade Center attack: helping the helpers: the role of critical incident stress management. Crit Care2001; 5: 1–3. https://doi.org/10.1186/cc1059
SendlerJDRutkowskaAMakara-StudzinskaM. How the exposure to trauma has hindered physicians' capacity to heal: prevalence of PTSD among healthcare workers. Eur J Psychiatr2016; 30(4): 321–334.
39.
Kendall-TackettKBeckCT. Secondary traumatic stress and moral injury in maternity care providers: a narrative and exploratory review. Front Glob Womens Health2022; 3: 835811. https://doi.org/10.3389/fgwh.2022.835811
40.
ShelefLSchiffMPat-HorenczykR, et al.COVID-19 vs. terrorism: contribution of the CO theory to the process of coping with invisible threats. J Psychiatr Res2022; 147: 176–182. https://doi.org/10.1016/j.jpsychires.2022.01.023
41.
ShelefLBechorUOhayonO, et al.The psychological impact of exposure to battle on medics: a cross-sectional study of ex-soldiers who sought help from the IDF combat reaction unit. Mil Med2024; 189(3–4): e781–e788. https://doi.org/10.1093/milmed/usad368
42.
Daphna-TekoahSHarelA. “Routine trauma”—Awareness of combat trauma in women combatants. Psychol Trauma2023; 17: 29–37. https://doi.org/10.1037/tra0001622
43.
NeriaYBesserAKiperD, et al.A longitudinal study of posttraumatic stress disorder, depression, and generalized anxiety disorder in Israeli civilians exposed to war trauma. J Trauma Stress2010; 23(3): 322–330. https://doi.org/10.1002/jts.20522
44.
Sberro-CohenSAmitIBarenboimE, et al.Resilience, sense of danger, and reporting in wartime: a cross-sectional study of healthcare personnel in a general hospital. Hum Resour Health2023; 21: 81. https://doi.org/10.1186/s12960-023-00866-w
45.
GanzFDMargalithIBenbenishtyJ, et al.A conflict of values: nurses’ willingness to work under threatening conditions. J Nurs Scholarsh2019; 51(3): 281–288. https://doi.org/10.1111/jnu.12466
46.
KingN. Using templates in the thematic analysis of text. In: CassellCSymonG (eds). Essential guide to qualitative methods in organizational research. Sage, 2004, pp. 257–270.
47.
TimmermansSTavoryI. Theory construction in qualitative research: from grounded theory to abductive analysis. Sociol Theor2012; 30(3): 167–186. https://doi.org/10.1177/0735275112457914
48.
Bar-ElYReisnerSBeyarR. Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the Second Lebanon War. Med Health Care Philos2014; 17: 155–160. https://doi.org/10.1007/s11019-013-9517-x
49.
BuchbinderMFahrenwaldNDevineD. Moral stress and moral distress in healthcare: confronting challenges in contemporary clinical practice. HEC Forum2023; 35: 1–15. https://pmc.ncbi.nlm.nih.gov/articles/PMC10758677/
PeteetJRWitvlietCVOGlasG, et al.Accountability as a virtue in medicine: from theory to practice. Philos Ethics Humanit Med2023; 18(1): 3. https://doi.org/10.1186/s13010-023-00129-5
WeisskopfV. The Jewish Hospital in Budapest under the Nazi occupation (1944–1945). Harefuah2008; 147(81–84): 92.
55.
SvobodaTHenryBShulmanL, et al.Public health measures to control the spread of severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med2004; 350: 2352–2361. https://doi.org/10.1056/NEJMoa032111
56.
BergronRECurielTJ. After the storm: health care infrastructure in post-Katrina New Orleans. N Engl J Med2006; 354: 1549–1552.
57.
Naamati-SchneiderLZaksO. Public hospitals in crisis: managerial and strategic adaptation. In: TarbaSCooperC (eds). Business under crisis. Volume II: organisational adaptations. : Springer International Publishing, 2022, pp. 43–64. DOI: 10.1007/978-3-030-76575-0_3.
58.
GillieGNaamati-SchneiderLPikkelD. Cultivating psychological resilience of Israeli medical directors of COVID-19 divisions: the dynamic spheres of Salutogenics. Front Public Health2022; 10: 801297. https://doi.org/10.3389/fpubh.2022.801297
59.
AtkinsonMKBiddingerPDChughtaiMA, et al.Assessing health care leadership and management for resilience and performance during crisis: the HERO-36. Health Care Manag Rev2024; 49(1): 14–22. https://doi.org/10.1097/HMR.0000000000000387
60.
GiwaAOUrdanetaAEWedroB. Call of Duty - what are physicians' obligations during crises?The Journal of Emergency Medicine2022; 63(4): 592–596. https://doi.org/10.1016/j.jemermed.2022.07.017
61.
Daphna-TekoahSHarel-ShalevA. Living in a movie—Israeli women combatants in conflict zones. Womens Stud Int Forum2014; 44: 26–34. https://doi.org/10.1016/j.wsif.2014.03.002
62.
Daphna-TekoahSHarel-ShalevA. Beyond binaries: analyzing violent state actors in critical studies. Crit Stud Terrorism2017; 10(2): 253–273. https://doi.org/10.1080/17539153.2017.1329783
63.
ShelefLFruchterEGordonS, et al.Impairment among soldiers who were exposed to combat during military operation. Int J Psychiatry2018; 3(1): 1–5.
64.
DobieszVASchwidMDiasRD, et al.Maintaining health professional education during war: a scoping review. Med Educ2022; 56(8): 793–804. https://doi.org/10.1111/medu.14808
65.
GoralAFeder-BubisPLahadM, et al.“In the middle, between anxiety victims and PTSD, there are people that have some kind of a disorder that has no name yet”: insights about the traumatic stress consequences of exposure to ongoing threat. Trauma Care2022; 2(2): 185–196. https://doi.org/10.3390/traumacare2020015
66.
KazmirchukAYarmoliukYLurinI, et al.Ukraine's experience with management of combat casualties using NATO's four-tier “Changing as Needed” healthcare system. World J Surg2022; 46(12): 2858–2862. https://doi.org/10.1007/s00268-022-06718-3
67.
GarrySChecchiF. Armed conflict and public health: into the 21st century. J Public Health2020; 42(3): e287–e298. https://doi.org/10.1093/pubmed/fdz095
68.
Shafran-TikvaSChinitzDSternZ, et al.Violence against physicians and nurses in a hospital: how does it happen? A mixed-methods study. Isr J Health Pol Res2017; 6: 1–12. https://doi.org/10.1186/s13584-017-0183-y
69.
AgbloyorEA. A call to duty; but duty to who? Voices of healthcare providers in conflict zones. Narrat Inq Bioeth2023; 13(3): 181–185. https://doi.org/10.1353/nib.2023.a924188
70.
MolendijkTKramerEHVerweijD. Moral injury in relation to public debates: the role of societal misrecognition in moral conflict-colored trauma among soldiers. Soc Sci Med2021; 272: 113718.
71.
ShayJ. Achilles in Vietnam: combat trauma and the undoing of character. : Scribner, 1994.
72.
LitzBTSteinNDelaneyE, et al.Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev2009; 29(8): 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
